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

要不是獲得獎學金去古巴學醫，

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

而且立志回到那些

and a commitment to go back

像他們生長背景的地方服務：

to places like the ones they'd come from —

偏遠的農村、山區和貧民區。

remote farmlands, mountains, ghettos —

成為醫生，

to become doctors for people like themselves,

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.

學校的宗旨是：

Its mission, to train physicians for the people

為最需要醫生的人培訓醫生，

who need them the most:

為世界上 10 多億從沒看過醫生的人。

the over one billion

這些人從出生到死亡，

who have never seen a doctor,

一輩子生活在各種貧窮線水平之下。

the people who live and die

這所醫學院的學生很特殊，

under every poverty line ever invented.

他們是學校最大的風險，

Its students defy all norms.

也是最大的勝算，

They're the school's biggest risk

他們從世界上最窮的地區被招收進來。

and also its best bet.

學校相信

They're recruited from the poorest,

他們不單可以成為好醫生，

most broken places on our planet

而且是他們社群迫切需要的卓越醫生。

by a school that believes they can become

他們也願意去多數醫生不去的地方，

not just the good

這些地方不但貧窮，

but the excellent physicians

甚至通常很危險。

their communities desperately need,

醫療包裡要帶蛇毒解毒劑，

that they will practice where most doctors don't,

或是四處出診，

in places not only poor

遊走在被毒品、黑幫、子彈摧殘得 千瘡百孔的地區，

but oftentimes dangerous,

就是他們的家園。

carrying venom antidotes in their backpacks

培訓的目的

or navigating neighborhoods

是要透過這些醫生， 就近提供社區醫療照護，

riddled by drugs, gangs and bullets,

提升貧窮地區的衛生水準，

their home ground.

甚至顛覆醫學訓練和行醫的方式；

The hope is that they will help

這些醫生會成為醫療先鋒，

transform access to care,

將衛生保健推到世界每一個角落，

the health picture in impoverished areas,

任務真的非常艱鉅。

and even the way medicine itself

兩個大暴風， 和「用行動實踐信念」的想法，

is learned and practiced,

催生了哈瓦那拉丁美洲醫學院，

and that they will become pioneers in our global reach

在 1998 創校。

for universal health coverage,

喬治和米奇兩個颶風

surely a tall order.

重襲加勒比海和中美洲，

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

造成 3 萬人死亡，

prompted creation of ELAM back in 1998.

250 萬人無家可歸。

The Hurricanes Georges and Mitch

數以百計的古巴醫生自願去救災，

had ripped through the Caribbean

不過他們一到那裡，

and Central America,

卻發現更大的災難：

leaving 30,000 dead

很多社區完全沒有醫療服務，

and two and a half million homeless.

偏鄉的醫院都關閉了。

Hundreds of Cuban doctors volunteered for disaster response,

因為人手短缺。

but when they got there,

有太多太多的嬰兒不到周歲就夭折。

they found a bigger disaster:

這群古巴醫生離開以後， 又會變成什麼樣呢？

whole communities with no healthcare,

必須有醫生接手，繼續提供醫療，

doors bolted shut on rural hospitals

但要去哪裡找醫生？怎麼訓練？

for lack of staff,

後來，一所哈瓦那海事學院的舊校園，

and just too many babies dying

由古巴衛生部接管，

before their first birthday.

改建成了拉丁美洲醫學院，

What would happen when these Cuban doctors left?

也就是 ELAM。

New doctors were needed to make care sustainable,

它提供學費、食宿，和小額生活津貼，

but where would they come from?

給數百名來自受災最重國家的學生。

Where would they train?

我在哈瓦那當記者，

In Havana, the campus of a former naval academy

看著首批 97 位尼加拉瓜學生

was turned over to the Cuban Health Ministry

在 1999 年 3 月來報到，

to become the Latin American Medical School,

搬進了幾乎未整修的學校宿舍，

ELAM.

幫教授們一下清空教室、

Tuition, room and board, and a small stipend

一下又搬進課桌椅和顯微鏡。

were offered to hundreds of students

接下來的幾年，

from the countries hardest hit by the storms.

美洲各國的政府

As a journalist in Havana,

都來幫自己的學生申請獎學金。

I watched the first 97 Nicaraguans arrive

美國國會黑人同盟

in March 1999,

也申請並且獲得數百個獎學金名額，

settling into dorms barely refurbished

提供給美國的年輕人。

and helping their professors not only sweep out the classrooms

至今 2 萬 3 千名校友，

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

總共來自 83 個國家，

Over the next few years,

遍佈美洲、非洲和亞洲，

governments throughout the Americas

新生的國籍也增加到 123 個國家，

requested scholarships for their own students,

半數以上是年輕的女性，

and the Congressional Black Caucus

來自 100 個不同種族，

asked for and received hundreds of scholarships

說 50 種不同的語言，

for young people from the USA.

WHO 總幹事陳馮富珍說過：

Today, among the 23,000

「終於，如果你是窮人、

are graduates from 83 countries

女性、

in the Americas, Africa and Asia,

或是原住民，

and enrollment has grown to 123 nations.

這些條件反而變成獨特的優勢，

More than half the students are young women.

這種價值觀使 ELAM 與眾不同。」

They come from 100 ethnic groups,

魯瑟．卡斯第羅來自 托卡馬喬市的聖佩德羅，

speak 50 different languages.

位在洪都拉斯的大西洋岸。

WHO Director Margaret Chan said,

這個村落沒有自來水、

"For once, if you are poor, female,

沒有電力，

or from an indigenous population,

從鎮上到那裡還得走好幾個鐘頭，

you have a distinct advantage,

或跟我一樣，碰運氣搭小貨車，

an ethic that makes this medical school unique."

沿大西洋岸，趁著退潮行駛。

Luther Castillo comes from San Pedro de Tocamacho

魯瑟

on the Atlantic coast of Honduras.

是托市 40 個上過小學的孩子之一，

There's no running water,

加利福納黑人原住民兒童，

no electricity there,

這些原住民佔宏都拉斯兩成人口。

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

離他們最近的醫院

or take your chances in a pickup truck like I did

在好幾哩外，緊急時根本救命不及。

skirting the waves of the Atlantic.

魯瑟每天得要走上 3 個小時，

Luther was one of 40 Tocamacho children

才能到中學上課，

who started grammar school,

只有 17 個小孩能上中學，

the sons and daughters of a black indigenous people

只有 5 個繼續唸高中，

known as the Garífuna,

只有 1 個最後上了大學：

20 percent of the Honduran population.

魯瑟來到了 ELAM 醫學院！

The nearest healthcare was fatal miles away.

成為第一批加利福納畢業生。

Luther had to walk three hours every day

整個宏都拉斯歷史， 之前只曾有過 2 個加利福納族醫生，

to middle school.

現在有 69 個！

Only 17 made that trip.

多虧有 ELAM 醫學院。

Only five went on to high school,

非常問題需要非常手段，

and only one to university:

靠偉大的理想、想像力和膽識激發，

Luther, to ELAM,

但手段也必須行得通。

among the first crop of Garífuna graduates.

ELAM 沒有實證可行的現成課程，

Just two Garífuna doctors had preceded them

所以大家必須辛苦地摸索學習，

in all of Honduran history.

邊學邊做，邊調整。

Now there are 69, thanks to ELAM.

這些貧窮地區，就算是最聰明的學生，

Big problems need big solutions,

也沒能力立刻開始 6 年醫學訓練。

sparked by big ideas, imagination and audacity,

所以學校設計了科學銜接課程，

but also solutions that work.

再上語言課。

ELAM's faculty had no handy evidence base

學生來自馬普切族、克丘亞族、 瓜拉尼族、加里福納族

to guide them, so they learned the hard way,

多為原住民，

by doing and correcting course as they went.

學過西班牙語，成為第二語言；

Even the brightest students

也有說克里奧爾語的海地學生。

from these poor communities

所以西班牙文成為

weren't academically prepared

上醫學先修課程之前的先修課程。

for six years of medical training,

即使如此，

so a bridging course was set up in sciences.

在古巴，

Then came language:

音樂、食物、氣味等等，

these were Mapuche, Quechuas, Guaraní, Garífuna,

一切風情民俗都截然不同，

indigenous peoples

所以全校師生都變成一家人： 「ELAM 之家」

who learned Spanish as a second language,

宗教信仰多元：跨原住民信仰、

or Haitians who spoke Creole.

約魯巴信仰、穆斯林信仰、 基督教福音教派，

So Spanish became part

擁抱多元成為生活的方式。

of the pre-pre-med curriculum.

為什麼會有這麼多國家的人

Even so, in Cuba,

爭取這些獎學金呢？

the music, the food, the smells,

第一：他們的國家沒有足夠的醫生，

just about everything was different,

就算夠醫生，

so faculty became family, ELAM home.

也分佈不均，漠視窮鄉僻壤。

Religions ranged from indigenous beliefs

因為全球的衛生醫療危機，

to Yoruba, Muslim and Christian evangelical.

是受人力資源短缺危機所致，

Embracing diversity became a way of life.

光是基本醫療需求， 就缺少 4 到 7 百萬名醫療人員，

Why have so many countries

世界各地都有這個問題。

asked for these scholarships?

醫生都集中在都市，

First, they just don't have enough doctors,

而都市只占全球人口的半數。

and where they do, their distribution

而且醫生都集中在市內，

is skewed against the poor,

不在週邊的貧民區或南洛杉磯。

because our global health crisis

在美國，

is fed by a crisis in human resources.

我們雖然有健保改革，

We are short four to seven million health workers

卻短缺醫療專業人員。

just to meet basic needs,

到 2020 年，

and the problem is everywhere.

會少 4 萬 5 千名基層醫療醫師。

Doctors are concentrated in the cities,

我們也是造成問題的元凶之一：

where only half the world's people live,

美國是吸引全世界最多 發展中國家醫師的國家，

and within cities,

第二個學生們搶進古巴的理由，

not in the shantytowns or South L.A.

是這個小島本身的衛生水準，

Here in the United States,

基層醫療做得很好。

where we have healthcare reform,

醫學權威《The Lancet》期刊的委員會

we don't have the professionals we need.

把古巴列為全球醫療衛生 最佳的中收入國家之一。

By 2020, we will be short

「救助兒童會」評選古巴為

45,000 primary care physicians.

最適合生小孩的拉丁美洲國家。

And we're also part of the problem.

古巴人的平均壽命跟美國人一樣長，

The United States is the number one importer

嬰兒死亡率比美國低，

of doctors from developing countries.

且差距較少；

The second reasons students flock to Cuba

但是古巴花在醫療衛生的人均消費，

is the island's own health report card,

卻只有美國人的 1 / 20。

relying on strong primary care.

ELAM 對課業要求很嚴格，

A commission from The Lancet

但學生畢業率達 80%。

rates Cuba among the best performing

主修科目跟一般醫學院一樣：

middle-income countries in health.

基礎科學與臨床科學。

Save the Children ranks Cuba

但是也有很大的不同：

the best country in Latin America to become a mother.

首先，訓練走出了象牙塔，

Cuba has similar life expectancy

進入診間教室和社區，

and lower infant mortality than the United States,

就是多數畢業生將來執業的地方，

with fewer disparities,

當然他們也有講座和醫院輪班，

while spending per person

但是社區實習從新生入學就開始了。

one 20th of what we do on health

其次，學生注重全人治療，

here in the USA.

兼顧病人的生理和心理，

Academically, ELAM is tough,

並且考量病人的家庭、社群，

but 80 percent of its students graduate.

和文化背景。

The subjects are familiar —

第三，他們學習公共衛生，

basic and clinical sciences —

評估病人的飲水、家居環境，

but there are major differences.

和社經條件。

First, training has moved out of the ivory tower

第四，他們學習到

and into clinic classrooms and neighborhoods,

仔細地問診

the kinds of places most of these grads will practice.

加上周全的臨床檢測，

Sure, they have lectures and hospital rotations too,

可以深入了解病情，幫助診斷，

but community-based learning starts on day one.

省下確診技術的昂貴費用。

Second, students treat the whole patient,

最後，他們不斷被教育

mind and body,

預防的重要性，

in the context of their families, their communities

尤其是現在慢性疾病

and their culture.

拖垮世界各國的衛生醫療。

Third, they learn public health:

這種實作學習

to assess their patients' drinking water, housing,

也注重團隊精神，

social and economic conditions.

學生們學習彼此合作，

Fourth, they are taught

也學習領導團隊，

that a good patient interview

並且保持謙遜的態度。

and a thorough clinical exam

一畢業，這些新科醫生就開始

provide most of the clues for diagnosis,

把知識分享給助理護士、助產士、

saving costly technology for confirmation.

社區衛生工作者，

And finally, they're taught over and over again

幫助他們更能勝任工作，

the importance of prevention,

而不是取代他們，

especially as chronic diseases

也會跟巫醫和傳統治療工作者合作。

cripple health systems worldwide.

ELAM 的畢業生

Such an in-service learning

是否證明了這麼大膽的嘗試奏效？

also comes with a team approach,

從數十個計畫

as much how to work in teams

可以窺知他們的能力。

as how to lead them,

像是加利福納的畢業生，

with a dose of humility.

不但回到家鄉工作，

Upon graduation, these doctors share

還集結社區力量，

their knowledge with nurse's aids, midwives,

蓋了宏都拉斯第一間原住民醫院。

community health workers,

在一位建築師的幫助下，

to help them become better at what they do,

居民們胼手胝足， 憑空打造出一座醫院。

not to replace them,

2007 年 12 月，收了首批病患

to work with shamans and traditional healers.

到現在，這間醫院收容過

ELAM's graduates:

將近 100 萬的求診人次，

Are they proving this audacious experiment right?

而政府也很關注，

Dozens of projects give us an inkling

以這所醫院做為宏都拉斯

of what they're capable of doing.

農村公共醫療的模範，

Take the Garífuna grads.

ELAM 的畢業生聰明、

They not only went to work back home,

堅強能幹，

but they organized their communities to build

而且全心奉獻。

Honduras' first indigenous hospital.

2010 年 1 月海地地震，

With an architect's help,

傷慟的悲劇：

residents literally raised it from the ground up.

人們被埋在 3 千萬噸的瓦礫碎片下，

The first patients walked through the doors

悲痛難當！

in December 2007,

340 個古巴醫生

and since then, the hospital has received

已經長期駐地救治傷患。

nearly one million patient visits.

還有很多醫生正在趕過來， 但仍需要更多的醫生。

And government is paying attention,

在 ELAM，學生們晝夜不停地

upholding the hospital as a model

聯繫 2 千位畢業醫生。

of rural public health for Honduras.

結果，好幾百位醫生趕來海地，

ELAM's graduates are smart,

總共來自 27 個國家，

strong and also dedicated.

包括撒哈拉的馬利、

Haiti, January 2010.

聖露西亞、玻利維亞、 智利、美國等國家，

The pain.

彼此用流利的西班牙語溝通，

People buried under 30 million tons of rubble.

也能了解病人用克里奧爾語描述病情，

Overwhelming.

幸好有這些海地學生，

Three hundred forty Cuban doctors

從古巴 ELAM 醫學院及時飛過來。

were already on the ground long term.

很多人待了好幾個月，

More were on their way. Many more were needed.

甚至爆發霍亂疫情，仍堅守不離。

At ELAM, students worked round the clock

數百位海地的 ELAM 畢業生，

to contact 2,000 graduates.

必須收拾殘局重建家園，

As a result, hundreds arrived in Haiti,

忍住自己的傷慟，

27 countries' worth, from Mali in the Sahara

然後一肩扛起重擔，

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

為海地建立全新的公共衛生系統。

They spoke easily to each other in Spanish

現在，有了世界組織和各國政府資助

and listened to their patients in Creole

包括挪威、古巴、巴西等國家，

thanks to Haitian medical students

已經蓋好數十所新衛生中心，

flown in from ELAM in Cuba.

找好人手，

Many stayed for months,

其中 35 所，院長是 ELAM 畢業生。

even through the cholera epidemic.

不過，海地事件

Hundreds of Haitian graduates

也暴露了很多國家面臨的更大問題。

had to pick up the pieces,

我們來看一下：

overcome their own heartbreak,

截至 2012 年爆發霍亂時， 共有 748 個海地畢業生，

and then pick up the burden

其中近半數在公共衛生單位工作，

of building a new public health system for Haiti.

但是有 1/4 失業，

Today, with aid of organizations and governments

還有 110 人被迫出國找工作。

from Norway to Cuba to Brazil,

最理想的情況是，

dozens of new health centers have been built,

這些畢業生都能順利就業，

staffed, and in 35 cases, headed

強化公共衛生體系，

by ELAM graduates.

到從未有過醫生的地方開業。