Gail Reed: Where to train the world's doctors? Cuba.

譯者: Harry Chen 審譯者: Yesbydefault 倪文娟

I want to tell you

我要告訴大家，

how 20,000 remarkable young people

為什麼 2 萬個傑出的年輕人，

from over 100 countries

來自 100 多個國家，

ended up in Cuba

當初會選擇去古巴，

and are transforming health in their communities.

而現在正在改善他們的社區衛生。

Ninety percent of them would never

九成的這些年輕人 本來永遠不會離開家鄉，

have left home at all

if it weren't for a scholarship to study medicine in Cuba

要不是獲得獎學金去古巴學醫，

and a commitment to go back

而且立志回到那些

to places like the ones they'd come from —

像他們生長背景的地方服務：

remote farmlands, mountains, ghettos —

偏遠的農村、山區和貧民區。

to become doctors for people like themselves,

成為醫生，

服務跟自己一樣的弱勢，

to walk the walk.

用行動實踐信念。

Havana's Latin American Medical School:

哈瓦那拉丁美洲醫學院

It's the largest medical school in the world,

是世界上最大的醫學院，

graduating 23,000 young doctors

從 2005 年第一班畢業， 至今已有 2 萬 3 千名畢業生，

since its first class of 2005,

還有大約 1 萬名在學。

with nearly 10,000 more in the pipeline.

Its mission, to train physicians for the people

學校的宗旨是：

為最需要醫生的人培訓醫生，

who need them the most:

the over one billion

為世界上 10 多億從沒看過醫生的人。

who have never seen a doctor,

the people who live and die

這些人從出生到死亡，

under every poverty line ever invented.

一輩子生活在各種貧窮線水平之下。

Its students defy all norms.

這所醫學院的學生很特殊，

They're the school's biggest risk

他們是學校最大的風險，

and also its best bet.

也是最大的勝算，

They're recruited from the poorest,

他們從世界上最窮的地區被招收進來。

most broken places on our planet

by a school that believes they can become

學校相信

他們不單可以成為好醫生，

not just the good

but the excellent physicians

而且是他們社群迫切需要的卓越醫生。

their communities desperately need,

that they will practice where most doctors don't,

他們也願意去多數醫生不去的地方，

in places not only poor

這些地方不但貧窮，

but oftentimes dangerous,

甚至通常很危險。

carrying venom antidotes in their backpacks

醫療包裡要帶蛇毒解毒劑，

or navigating neighborhoods

或是四處出診，

riddled by drugs, gangs and bullets,

遊走在被毒品、黑幫、子彈摧殘得 千瘡百孔的地區，

their home ground.

就是他們的家園。

The hope is that they will help

培訓的目的

是要透過這些醫生， 就近提供社區醫療照護，

transform access to care,

the health picture in impoverished areas,

提升貧窮地區的衛生水準，

and even the way medicine itself

甚至顛覆醫學訓練和行醫的方式；

is learned and practiced,

and that they will become pioneers in our global reach

這些醫生會成為醫療先鋒，

將衛生保健推到世界每一個角落，

for universal health coverage,

surely a tall order.

任務真的非常艱鉅。

Two big storms and this notion of "walk the walk"

兩個大暴風， 和「用行動實踐信念」的想法，

prompted creation of ELAM back in 1998.

催生了哈瓦那拉丁美洲醫學院，

在 1998 創校。

The Hurricanes Georges and Mitch

喬治和米奇兩個颶風

had ripped through the Caribbean

重襲加勒比海和中美洲，

and Central America,

leaving 30,000 dead

造成 3 萬人死亡，

and two and a half million homeless.

250 萬人無家可歸。

Hundreds of Cuban doctors volunteered for disaster response,

數以百計的古巴醫生自願去救災，

but when they got there,

不過他們一到那裡，

they found a bigger disaster:

卻發現更大的災難：

whole communities with no healthcare,

很多社區完全沒有醫療服務，

doors bolted shut on rural hospitals

偏鄉的醫院都關閉了。

for lack of staff,

因為人手短缺。

and just too many babies dying

有太多太多的嬰兒不到周歲就夭折。

before their first birthday.

What would happen when these Cuban doctors left?

這群古巴醫生離開以後， 又會變成什麼樣呢？

必須有醫生接手，繼續提供醫療，

New doctors were needed to make care sustainable,

but where would they come from?

但要去哪裡找醫生？怎麼訓練？

Where would they train?

In Havana, the campus of a former naval academy

後來，一所哈瓦那海事學院的舊校園，

was turned over to the Cuban Health Ministry

由古巴衛生部接管，

to become the Latin American Medical School,

改建成了拉丁美洲醫學院，

ELAM.

也就是 ELAM。

Tuition, room and board, and a small stipend

它提供學費、食宿，和小額生活津貼，

were offered to hundreds of students

給數百名來自受災最重國家的學生。

from the countries hardest hit by the storms.

As a journalist in Havana,

我在哈瓦那當記者，

I watched the first 97 Nicaraguans arrive

看著首批 97 位尼加拉瓜學生

in March 1999,

在 1999 年 3 月來報到，

settling into dorms barely refurbished

搬進了幾乎未整修的學校宿舍，

and helping their professors not only sweep out the classrooms

幫教授們一下清空教室、

but move in the desks and the chairs and the microscopes.

一下又搬進課桌椅和顯微鏡。

Over the next few years,

接下來的幾年，

governments throughout the Americas

美洲各國的政府

requested scholarships for their own students,

都來幫自己的學生申請獎學金。

and the Congressional Black Caucus

美國國會黑人同盟

asked for and received hundreds of scholarships

也申請並且獲得數百個獎學金名額，

for young people from the USA.

提供給美國的年輕人。

Today, among the 23,000

至今 2 萬 3 千名校友，

are graduates from 83 countries

總共來自 83 個國家，

in the Americas, Africa and Asia,

遍佈美洲、非洲和亞洲，

and enrollment has grown to 123 nations.

新生的國籍也增加到 123 個國家，

More than half the students are young women.

半數以上是年輕的女性，

They come from 100 ethnic groups,

來自 100 個不同種族，

speak 50 different languages.

說 50 種不同的語言，

WHO Director Margaret Chan said,

WHO 總幹事陳馮富珍說過：

"For once, if you are poor, female,

「終於，如果你是窮人、

女性、

or from an indigenous population,

或是原住民，

you have a distinct advantage,

這些條件反而變成獨特的優勢，

an ethic that makes this medical school unique."

這種價值觀使 ELAM 與眾不同。」

Luther Castillo comes from San Pedro de Tocamacho

魯瑟．卡斯第羅來自 托卡馬喬市的聖佩德羅，

on the Atlantic coast of Honduras.

位在洪都拉斯的大西洋岸。

There's no running water,

這個村落沒有自來水、

no electricity there,

沒有電力，

and to reach the village, you have to walk for hours

從鎮上到那裡還得走好幾個鐘頭，

or take your chances in a pickup truck like I did

或跟我一樣，碰運氣搭小貨車，

skirting the waves of the Atlantic.

沿大西洋岸，趁著退潮行駛。

Luther was one of 40 Tocamacho children

魯瑟

是托市 40 個上過小學的孩子之一，

who started grammar school,

加利福納黑人原住民兒童，

the sons and daughters of a black indigenous people

known as the Garífuna,

20 percent of the Honduran population.

這些原住民佔宏都拉斯兩成人口。

The nearest healthcare was fatal miles away.

離他們最近的醫院

在好幾哩外，緊急時根本救命不及。

Luther had to walk three hours every day

魯瑟每天得要走上 3 個小時，

to middle school.

才能到中學上課，

Only 17 made that trip.

只有 17 個小孩能上中學，

Only five went on to high school,

只有 5 個繼續唸高中，

and only one to university:

只有 1 個最後上了大學：

Luther, to ELAM,

魯瑟來到了 ELAM 醫學院！

among the first crop of Garífuna graduates.

成為第一批加利福納畢業生。

Just two Garífuna doctors had preceded them

整個宏都拉斯歷史， 之前只曾有過 2 個加利福納族醫生，

in all of Honduran history.

現在有 69 個！

Now there are 69, thanks to ELAM.

多虧有 ELAM 醫學院。

Big problems need big solutions,

非常問題需要非常手段，

sparked by big ideas, imagination and audacity,

靠偉大的理想、想像力和膽識激發，

but also solutions that work.

但手段也必須行得通。

ELAM's faculty had no handy evidence base

ELAM 沒有實證可行的現成課程，

to guide them, so they learned the hard way,

所以大家必須辛苦地摸索學習，

by doing and correcting course as they went.

邊學邊做，邊調整。

Even the brightest students

這些貧窮地區，就算是最聰明的學生，

from these poor communities

weren't academically prepared

也沒能力立刻開始 6 年醫學訓練。

for six years of medical training,

so a bridging course was set up in sciences.

所以學校設計了科學銜接課程，

Then came language:

再上語言課。

these were Mapuche, Quechuas, Guaraní, Garífuna,

學生來自馬普切族、克丘亞族、 瓜拉尼族、加里福納族

indigenous peoples

多為原住民，

who learned Spanish as a second language,

學過西班牙語，成為第二語言；

or Haitians who spoke Creole.

也有說克里奧爾語的海地學生。

So Spanish became part

所以西班牙文成為

上醫學先修課程之前的先修課程。

of the pre-pre-med curriculum.

Even so, in Cuba,

即使如此，

在古巴，

the music, the food, the smells,

音樂、食物、氣味等等，

just about everything was different,

一切風情民俗都截然不同，

so faculty became family, ELAM home.

所以全校師生都變成一家人： 「ELAM 之家」

Religions ranged from indigenous beliefs

宗教信仰多元：跨原住民信仰、

to Yoruba, Muslim and Christian evangelical.

約魯巴信仰、穆斯林信仰、 基督教福音教派，

Embracing diversity became a way of life.

擁抱多元成為生活的方式。

Why have so many countries

為什麼會有這麼多國家的人

asked for these scholarships?

爭取這些獎學金呢？

First, they just don't have enough doctors,

第一：他們的國家沒有足夠的醫生，

and where they do, their distribution

就算夠醫生，

is skewed against the poor,

也分佈不均，漠視窮鄉僻壤。

because our global health crisis

因為全球的衛生醫療危機，

is fed by a crisis in human resources.

是受人力資源短缺危機所致，

We are short four to seven million health workers

光是基本醫療需求， 就缺少 4 到 7 百萬名醫療人員，

just to meet basic needs,

世界各地都有這個問題。

and the problem is everywhere.

Doctors are concentrated in the cities,

醫生都集中在都市，

where only half the world's people live,

而都市只占全球人口的半數。

and within cities,

而且醫生都集中在市內，

not in the shantytowns or South L.A.

不在週邊的貧民區或南洛杉磯。

Here in the United States,

在美國，

where we have healthcare reform,

我們雖然有健保改革，

we don't have the professionals we need.

卻短缺醫療專業人員。

By 2020, we will be short

到 2020 年，

會少 4 萬 5 千名基層醫療醫師。

45,000 primary care physicians.

And we're also part of the problem.

我們也是造成問題的元凶之一：

The United States is the number one importer

美國是吸引全世界最多 發展中國家醫師的國家，

of doctors from developing countries.

The second reasons students flock to Cuba

第二個學生們搶進古巴的理由，

is the island's own health report card,

是這個小島本身的衛生水準，

relying on strong primary care.

基層醫療做得很好。

A commission from The Lancet

醫學權威《The Lancet》期刊的委員會

rates Cuba among the best performing

把古巴列為全球醫療衛生 最佳的中收入國家之一。

middle-income countries in health.

Save the Children ranks Cuba

「救助兒童會」評選古巴為

the best country in Latin America to become a mother.

最適合生小孩的拉丁美洲國家。

Cuba has similar life expectancy

古巴人的平均壽命跟美國人一樣長，

and lower infant mortality than the United States,

嬰兒死亡率比美國低，

with fewer disparities,

且差距較少；

while spending per person

但是古巴花在醫療衛生的人均消費，

one 20th of what we do on health

卻只有美國人的 1 / 20。

here in the USA.

Academically, ELAM is tough,

ELAM 對課業要求很嚴格，

but 80 percent of its students graduate.

但學生畢業率達 80%。

The subjects are familiar —

主修科目跟一般醫學院一樣：

basic and clinical sciences —

基礎科學與臨床科學。

but there are major differences.

但是也有很大的不同：

First, training has moved out of the ivory tower

首先，訓練走出了象牙塔，

and into clinic classrooms and neighborhoods,

進入診間教室和社區，

the kinds of places most of these grads will practice.

就是多數畢業生將來執業的地方，

Sure, they have lectures and hospital rotations too,

當然他們也有講座和醫院輪班，

but community-based learning starts on day one.

但是社區實習從新生入學就開始了。

Second, students treat the whole patient,

其次，學生注重全人治療，

mind and body,

兼顧病人的生理和心理，

in the context of their families, their communities

並且考量病人的家庭、社群，

and their culture.

和文化背景。

Third, they learn public health:

第三，他們學習公共衛生，

to assess their patients' drinking water, housing,

評估病人的飲水、家居環境，

social and economic conditions.

和社經條件。

Fourth, they are taught

第四，他們學習到

that a good patient interview

仔細地問診

and a thorough clinical exam

加上周全的臨床檢測，

provide most of the clues for diagnosis,

可以深入了解病情，幫助診斷，

saving costly technology for confirmation.

省下確診技術的昂貴費用。

And finally, they're taught over and over again

最後，他們不斷被教育

the importance of prevention,

預防的重要性，

especially as chronic diseases

尤其是現在慢性疾病

cripple health systems worldwide.

拖垮世界各國的衛生醫療。

Such an in-service learning

這種實作學習

also comes with a team approach,

也注重團隊精神，

as much how to work in teams

學生們學習彼此合作，

as how to lead them,

也學習領導團隊，

with a dose of humility.

並且保持謙遜的態度。

Upon graduation, these doctors share

一畢業，這些新科醫生就開始

把知識分享給助理護士、助產士、

their knowledge with nurse's aids, midwives,

community health workers,

社區衛生工作者，

to help them become better at what they do,

幫助他們更能勝任工作，

not to replace them,

而不是取代他們，

to work with shamans and traditional healers.

也會跟巫醫和傳統治療工作者合作。

ELAM's graduates:

ELAM 的畢業生

Are they proving this audacious experiment right?

是否證明了這麼大膽的嘗試奏效？

Dozens of projects give us an inkling

從數十個計畫

of what they're capable of doing.

可以窺知他們的能力。

Take the Garífuna grads.

像是加利福納的畢業生，

They not only went to work back home,

不但回到家鄉工作，

but they organized their communities to build

還集結社區力量，

Honduras' first indigenous hospital.

蓋了宏都拉斯第一間原住民醫院。

With an architect's help,

在一位建築師的幫助下，

residents literally raised it from the ground up.

居民們胼手胝足， 憑空打造出一座醫院。

The first patients walked through the doors

2007 年 12 月，收了首批病患

in December 2007,

and since then, the hospital has received

到現在，這間醫院收容過

nearly one million patient visits.

將近 100 萬的求診人次，

And government is paying attention,

而政府也很關注，

upholding the hospital as a model

以這所醫院做為宏都拉斯

of rural public health for Honduras.

農村公共醫療的模範，

ELAM's graduates are smart,

ELAM 的畢業生聰明、

strong and also dedicated.

堅強能幹，

而且全心奉獻。

Haiti, January 2010.

2010 年 1 月海地地震，

The pain.

傷慟的悲劇：

People buried under 30 million tons of rubble.

人們被埋在 3 千萬噸的瓦礫碎片下，

Overwhelming.

悲痛難當！

Three hundred forty Cuban doctors

340 個古巴醫生

were already on the ground long term.

已經長期駐地救治傷患。

More were on their way. Many more were needed.

還有很多醫生正在趕過來， 但仍需要更多的醫生。

At ELAM, students worked round the clock

在 ELAM，學生們晝夜不停地

to contact 2,000 graduates.

聯繫 2 千位畢業醫生。

As a result, hundreds arrived in Haiti,

結果，好幾百位醫生趕來海地，

27 countries' worth, from Mali in the Sahara

總共來自 27 個國家，

包括撒哈拉的馬利、

to St. Lucia, Bolivia, Chile and the USA.

聖露西亞、玻利維亞、 智利、美國等國家，

They spoke easily to each other in Spanish

彼此用流利的西班牙語溝通，

and listened to their patients in Creole

也能了解病人用克里奧爾語描述病情，

thanks to Haitian medical students

幸好有這些海地學生，

flown in from ELAM in Cuba.

從古巴 ELAM 醫學院及時飛過來。

Many stayed for months,

很多人待了好幾個月，

even through the cholera epidemic.

甚至爆發霍亂疫情，仍堅守不離。

Hundreds of Haitian graduates

數百位海地的 ELAM 畢業生，

had to pick up the pieces,

必須收拾殘局重建家園，

overcome their own heartbreak,

忍住自己的傷慟，

and then pick up the burden

然後一肩扛起重擔，

of building a new public health system for Haiti.

為海地建立全新的公共衛生系統。

Today, with aid of organizations and governments

現在，有了世界組織和各國政府資助

from Norway to Cuba to Brazil,

包括挪威、古巴、巴西等國家，

dozens of new health centers have been built,

已經蓋好數十所新衛生中心，

staffed, and in 35 cases, headed

找好人手，

其中 35 所，院長是 ELAM 畢業生。

by ELAM graduates.

Yet the Haitian story

不過，海地事件

also illustrates some of the bigger problems

也暴露了很多國家面臨的更大問題。

faced in many countries.

Take a look:

我們來看一下：

748 Haitian graduates by 2012, when cholera struck,

截至 2012 年爆發霍亂時， 共有 748 個海地畢業生，

nearly half working in the public health sector

其中近半數在公共衛生單位工作，

but one quarter unemployed,

但是有 1/4 失業，

and 110 had left Haiti altogether.

還有 110 人被迫出國找工作。

So in the best case scenarios,

最理想的情況是，

these graduates are staffing

這些畢業生都能順利就業，

and thus strengthening public health systems,

強化公共衛生體系，

where often they're the only doctors around.

到從未有過醫生的地方開業。

In the worst cases, there are simply not enough jobs

最壞的情況，

公共衛生體系根本沒有足夠的職缺，

in the public health sector,

where most poor people are treated,

而這些通常是窮人看病的地方；

not enough political will, not enough resources,

政治決心不夠、

資源不夠、

not enough anything —

什麼東西都不夠，

just too many patients with no care.

只有太多缺乏醫療照護的病人。

The grads face pressure from their families too,

ELAM 畢業生也有家庭壓力，

desperate to make ends meet,

急需餵飽一家子。

so when there are no public sector jobs,

所以如果公共衛生單位沒有職缺，

these new MDs decamp into private practice,

這些新手醫生轉到私人醫院，

or go abroad to send money home.

有些人只好出國工作，

寄錢回家。

Worst of all, in some countries,

最糟糕的是，

有些國家，

medical societies influence accreditation bodies

醫學界會左右認證機關，

not to honor the ELAM degree,

不讓其承認 ELAM 的學歷，

fearful these grads will take their jobs

因為怕 ELAM 畢業生搶飯碗，

or reduce their patient loads and income.

或是搶走病人，害他們收入減少。

It's not a question of competencies.

這非關能力問題。

Here in the USA, the California Medical Board

在美國，加州醫學委員會

accredited the school after rigorous inspection,

經過嚴密審查後才認證這間學校，

and the new physicians are making good

這些 ELAM 畢業生表現優異，

on Cuba's big bet,

不負醫學院的期望，

passing their boards and accepted

他們通過醫師資格考試，

into highly respected residencies

進入信譽卓著的醫院擔任住院醫師，

from New York to Chicago to New Mexico.

從紐約、芝加哥到新墨西哥都有。

Two hundred strong, they're coming

兩百名 ELAM 精兵回到美國，

back to the United States energized,

滿腔熱忱，

and also dissatisfied.

但也非常不滿。

As one grad put it,

有一個畢業生說：

in Cuba, "We are trained to provide quality care

「在古巴，我們學到

用最少的資源，提供最高品質的醫護，

with minimal resources,

so when I see all the resources we have here,

所以當我看見美國醫院資源這麼多，

and you tell me that's not possible,

你們卻說做不到，

I know it's not true.

我知道事實不是這樣。

Not only have I seen it work, I've done the work."

我不止看過其他人辦到，

我還親自做到了！」

ELAM's graduates,

ELAM 的畢業生，

some from right here in D.C. and Baltimore,

有些正是來自 華盛頓特區及巴爾的摩這裡，

have come from the poorest of the poor

是窮人裡的最窮，

to offer health, education

他們想提供醫療服務、教育，

and a voice to their communities.

並為社區發聲。

They've done the heavy lifting.

他們突破萬難扛起重任，

Now we need to do our part

現在輪到我們盡一份心力，

to support the 23,000 and counting,

支持這 2 萬 3 千位年輕人，

人數還在增加。

我們所有的人—

All of us —

foundations, residency directors, press,

基金會、住院醫師訓練負責人、媒體、

entrepreneurs, policymakers, people —

企業家、決策者和人民，

need to step up.

都必須挺身而出。

We need to do much more globally

全世界都必須做得更多，

to give these new doctors the opportunity

給這些新科醫生機會，

to prove their mettle.

證明自己的堅毅；

They need to be able

他們必須能夠

to take their countries' licensing exams.

參加自己國家的證照考試，

They need jobs in the public health sector

他們需要工作機會，

服務於公共衛生單位，

or in nonprofit health centers

或是非營利衛生中心，

to put their training and commitment to work.

貢獻所學和決心。

They need the chance to be

他們需要機會

the doctors their patients need.

成為病人最需要的醫生。

To move forward,

要邁向未來，

we may have to find our way back

我們可能必須先回到過去，

to that pediatrician who would

回到小時候那個熱心的小兒科醫師，

knock on my family's door

on the South Side of Chicago when I was a kid,

會來芝加哥南區敲我家的門，

who made house calls,

會四處出診，探訪病人，

who was a public servant.

真正的服務人群。

These aren't such new ideas

這些都不是醫學定位的新觀念，

of what medicine should be.

What's new is the scaling up

不同的只是把範圍擴大，

and the faces of the doctors themselves:

和這些生力軍的新面孔。

an ELAM graduate is more likely to be a she

ELAM 畢業生裡，

女性比例較高，

than a he;

多於男性。

In the Amazon, Peru or Guatemala,

在亞馬遜、秘魯或瓜地馬拉，

an indigenous doctor;

醫生很可能是原住民；

in the USA, a doctor of color

在美國，

醫生可能不是白人，

who speaks fluent Spanish.

而且會說流利的西班牙語。

She is well trained, can be counted on,

她們受過良好的訓練，

為人處事可靠，

and shares the face and culture of her patients,

來自跟病人相同的種族與文化，

and she deserves our support surely,

確實值得我們支持。

because whether by subway, mule, or canoe,

因為不論是坐地鐵、騾子或獨木舟，

she is teaching us to walk the walk.

她們都在啟發我們付諸行動。

Thank you. (Applause)

謝謝！（觀眾掌聲）