This project is made possible by a grant from the Bush Foundation.

Ground-breaking support system creates a win-win for medically-trained immigrants, Minnesota

While covering important events in our civic and cultural life, journalists typically focus on facts, controversies, issues and their impact. They rarely look through the lens of understanding leaders and leadership: who is leading the causes and creating change, how those leaders were motivated to tackle tough problems and create opportunities for their communities, and how they worked through the challenges that arose.

In this series, MinnPost is profiling such leaders in order to provide new insights — and, we hope in some cases, inspiration — for our readers. Each profile is paired with comments from members of a panel of experienced leaders and scholars of leadership. The project is made possible by a grant from the Bush Foundation.

They have treated patients in some of the world’s toughest places: Pakistan’s earthquake-stricken mountains, Burma’s embattled neighborhoods and crowded camps where Bhutanese families sought refuge.

What hundreds of these doctors and nurses haven’t been able to do is treat anyone in Minnesota where barriers to foreign-trained medical workers are formidable.

Now, they are surmounting those barriers — and, in the process, filling serious gaps in Minnesota’s health care delivery — thanks to Dr. Wilhelmina Holder and Stephen Nguyagwa.

From scratch, Holder and Nguyagwa built a ground-breaking system for supporting foreign-trained doctors and nurses in their struggle to win the credentials they need to practice in Minnesota.

Dr. Wilhelmina Holder
MinnPost/Sharon Schmickle
Dr. Wilhelmina Holder

Their leadership rose from deeply disappointing personal experience.

Doors were closed in Minnesota
Holder, 64, was a medical doctor whose career was shattered by civil war in her homeland, Liberia, where her father had been the president. Like millions of other refugees, she found herself absorbed for years in the distractions of settling in a new land and caring for the needs of a displaced family. By the time she was free to resume her practice, doors had closed to her in Minnesota, even though she had updated her skills.

“To my amazement, I realized I never would get into residency,” Holder said.

Instead, she channeled her energy into helping others overcome the same obstacles. She knew doctors who were working as taxi drivers and parking-lot attendants even while their communities cried for their professional services. She was determined to deploy her leadership skills on their behalf.

With help from her family and several donors, Holder founded the organization now known as the African & American Friendship Association for Cooperation & Development. Its most prominent initiative is the ambitious program to help foreign-trained medical workers win credentials to practice in Minnesota.

Stephen Nguyagwa
MinnPost/Sharon Schmickle
Stephen Nguyagwa

As the first program coordinator, Nguyagwa, 46, built systems for realizing Holder’s ambitions. He had worked for 15 years as a physical therapist in Kenya and Botswana before moving to the United States in 2003 in search of better schools for his children.

His wife, a nurse, eventually secured credentials and found work. But a career in physical therapy was out of his reach. The hurdles were just too high.

So Nguyagwa lost his bid to continue his career. What he hadn’t lost was his conviction that immigrant health-care workers had something to offer Minnesota. That became a guiding principle for his work.

“People who come here get so depressed, and they feel really beaten and really lost,” he said.

“We want them to consider themselves as professionals who are leaders,” he continued. “They are coming not to be helped, but they are coming to contribute.”

Drawing the blueprint
There were no blueprints for the work Holder and Nguyagwa had taken on. They had to learn on the fly how to help newcomers speaking a myriad of languages to learn English, study for exams, find mentors and navigate Minnesota’s complex culture of hospitals and clinics.

They fostered networks in which health-care professionals from around the world would help one another across cultural and language barriers. And they built their own network, partnering with state workforce centers, the International Institute of Minnesota and many different foundations and government agencies.

They also boosted statewide awareness of the untapped potential these foreign-trained professionals offered for helping Minnesota fill serious gaps in delivering health care where it is urgently needed: in family medicine, rural areas and immigrant communities.

A bargain for Minnesota
Foreign-trained doctors and nurses are eager to fill those needs, beginning with family medicine, a field too many American-trained doctors have shunned in favor of more prestigious and lucrative specialties.

Dr. Will Nicholson
umn.edu
Dr. Will Nicholson

“Our health-care system has done amazing things, but we are not producing the kind of doctors that people need in the amount needed,” said Dr. Will Nicholson at the University of Minnesota Medical School. “The doctors that are needed are front-line primary care doctors. …  And these people are absolutely fired up to do that work.”

They also are eager to serve in another area crying for doctors: small town hospitals. Show a rural Minnesota hospital to a doctor who has practiced in Somalia, and you will get a puzzled response: Why wouldn’t any doctor be eager to serve in a place where resources are so abundant?

Especially puzzling to the newcomers is the question of why they can’t treat fellow immigrants who urgently need care.

“I can’t imagine being a doctor, going to a new country, watching my countrymen have trouble accessing health care and knowing I could help them if I could just get certified,” Nicholson said. “By their life experiences, they are the kind of people who have strong connections to underserved communities.”

Nicholson directs a U of M program [PDF] that dovetails with the association’s work on behalf of foreign-trained doctors by helping prepare them for residencies.

“Their initial challenges are immense,” he said. “Often they come here with nothing but a suitcase. They don’t speak the language. They try to pass the (medical) board exams, learn English and get a job … all at the same time.”

That’s where Holder and Nguyagwa came in.

From dream to frustration
Building on the foundation set by Holder, Nguyagwa has served as friend, coach, morale-booster, networker and sometimes nagging scold to doctors like Yanelquis Acosta and Adalberto Torres.

Yanelquis Acosta, left, and Adalberto Torres
MinnPost/Sharon Schmickle
Yanelquis Acosta, left, and Adalberto Torres

The Cuban-trained doctors showed up in the association’s offices in 2008 speaking so little English that a relative had to help translate. Their story represents the dream-to-frustration experience of some 250 immigrants and refugees that the association has assisted since 2006.

Acosta and Torres, a married couple, earned medical degrees in Cuba, where Torres became deputy director of a 600-bed hospital, overseeing a 50-bed intensive care unit and 200 workers. Meanwhile, the Cuban government sent Acosta abroad — first, to Venezuela and then to Pakistan to treat victims of the 2005 Kashmir earthquake.

In 2006, the couple finally reunited in Venezuela, treating patients in a rural hospital. There, frustration over the Cuban system came to a head. As doctors, they enjoyed prestige and extra income. Still, with pay of about $25 a month, they struggled to support families back in Cuba. Having their own children seemed to be out of the question.

Their aspirations were limited, too.

“Cuba has many good things and bad things, but for me Cuba put a really, really low ceiling to my dreams,” Torres said. “You can live there. You can dream there. But you feel as if you are inside a casket. It is not a good life for me.”

So they took a drastic step: They went to the American Embassy and applied to come to the United States under a program that accepted Cuban medical professionals as refugees.

They did so knowing that they were taking a one-way street. The Cuban government never would allow them to go back home.

We didnt have any idea
What they didn’t know is that they also were jeopardizing their future as medical doctors.

After a brief stop in Florida, Acosta, now 33, and Torres, 39, came to Minnesota in 2008 where Acosta’s cousin had a home in Eagan. Never mind Minnesota’s brutal winters. The state would challenge them to learn English in a hurry, which was a critical first step on the road to winning medical credentials.

“Yanna’s cousin’s house was the only place where we could be close to the real American life and to English,” Torres said.

Minnesota offered another enticement: Holder’s association was poised to offer services that aren’t available in many other states, if any.

“We wanted to study for the medical license, but we didn’t have any idea how to do that until we came here,” Acosta said. “We didn’t even know which tests we needed to take. … It was super difficult, but we got a lot of help. We never felt alone in this process because in this program we found that a lot of physicians were like us, from other countries trying to get their license.”

A huge setback came, though, when her cousin left Minnesota for work in Houston. Acosta and Torres were homeless. They moved into Casa Guadalupana in St. Paul, a home for Latina women and their families operating in the Catholic tradition of Dorothy Day.

Rather than defeat, Acosta and Torres found new motivation at Casa Guadalupana: They would dedicate their service to the treatment of immigrants and refugees like themselves.

“Every two or three days, a car or van (would pull up) outside bringing little kids and a family without a home, without English, without anything,” Torres said. “That really changed our point of view about what we want to do in our future.”

Meanwhile, Nguyagwa and his staff doubled down on the moral support.

“They told us, ‘You are doctors. You can do this. You can keep your dreams alive.’ ” Torres said. “They do this job really, really well.”

Feeding patients, wiping beds
Beyond guidance in cramming for the three rigorous exams required by the Minnesota Board of Medical Practice, [PDF] Nguyagwa urged the Cubans to get practical experience in clinics and hospitals. Unable to land jobs, they volunteered at the University of Minnesota Medical Center. Torres, who had been deputy director of a 600-bed hospital, found himself helping feed patients and clean beds.

“I compare this part of my life to going to church … to washing feet,” he said. “I realized that even feeding patients and wiping beds I was doing something for the community.”

Once their English was good enough, they also worked at St. Mary’s Health Clinic in St. Paul, helping Spanish-speaking patients through their visits.

Back at the association offices, another boost came from connections with other aspiring doctors. Peer support networks were an essential part of the plan, Holder said.

“At the beginning, most doctors feel they can do it on their own,” she said. “But eventually they realize it is much easier doing it as a group. … The people feel embarrassed that they are not successful. But if they come together, they realize they are not the only ones who are struggling, and they can work together.”

And so, Nguyagwa organized networks of doctors from around the world, bringing them together in coffee shops and homes.

You can do this!
At one of those gatherings, the Cuban doctors met Khem Adhikari, 42, a physician from Bhutan who was struggling against the same tides that they were.

Khem Adhikari
MinnPost/Sharon Schmickle
Khem Adhikari

“We could share difficulties,” Adhikari said. “He (Torres) was here before me, so he told me how to go forward, what books to read.”

For months, the Bhutanese and Cuban doctors studied together at a library.

“More than one time, Khem called us and said, ‘I cannot go on with this.’ ” Torres said. “You could almost feel the fracture in his voice. … I said, ‘You can. You will feel this, this, this. But it’s OK. You can do this!’ ” 

Step by step
Meanwhile, Nguyagwa was walking them and other aspiring doctors through plans he had assembled under the advice of medical professionals and a few other immigrant doctors who had earned the right to practice in the state.

“Initially, I would tell them, ‘These are the steps … and walk them through the steps one by one,” he said.

Once the steps were understood, it was time to develop an individual plan of action. Nguyagwa would sit down and help each individual weigh the various options, then write a plan.

For Adhikari, the Bhutanese doctor, one option was to pay a professional agency such as Kaplan Medical to prep him for the exams.

He already had studied medicine for years in India. So, strapped for cash like most refugees, he chose to study independently.

Nguyagwa would strictly police his progress.

“My work was to keep calling him from time to time asking, ‘Are you on track with the plan you have in place? When are you sitting for the exams?’ ” Nguyagwa. “That kind of push helps someone to remember.”

The association also provided connections with professional mentors and modest financial support to cover the cost of books and materials.

Agonizing tradeoff
Like many refugees, Adhikari, 42, had come to the United States with little but a compelling personal story, an impressive professional résumé and a hefty share of hope.

During the 1990s, long-simmering ethnic tension in his homeland, Bhutan, exploded into violence, driving more than 100,000 people into refugee camps set up in Nepal by the U.N. High Commission for Refugees.

Adhikari, who had been in India for medical school, could not return to Bhutan. Instead, he treated his fellow Bhutanese in the camps for nearly 18 years with some time off to pursue post-residency training in India.

After years of international negotiations, the Bhutanese refugees entered one of the largest resettlement programs in world history. The United States agreed to accept up to 60,000 of them beginning in 2008.

By that time, Adhikari was working in Nepal as a physician for the agency charged with resettling the refugees, the International Organization for Migration.  Should he go himself?

“I was in a fix,” he said. “I would come to the United States at the risk of losing my profession.”

Staying behind, though, would leave him and his family without a country. There was no chance of returning to Bhutan. But in Nepal, they were temporary, foreign guests. 

“I am married, and I have two kids,” Adhikari said. “I was making them stateless.”

Life in the refugee camp was a struggle. Why not struggle in America?, he thought.

“I will go there, and I will do what I can,” he decided.

Arrived in winter
A physician friend was working in Minnesota, so that would be their destination. The family arrived in the Twin Cities in November 2009.

“It was snowing,” Adhikari recalled. “That caused some depression, of course, because we had always thought snow would be in the mountains only.”

His clear goal was to study for licensure exams and take them as quickly as possible. How to do that was not at all clear.

“In the beginning, it was really tough,” Adhikari said. “You never know what course to go, what books to read.”

By that time, though, word of Nguyagwa and the association had spread through immigrant and refugee circles.

“I was lucky enough to catch hold of Stephen,” Adhikari said. “Other people knew about him, so I came here.”

Tough competition
This year Adhikari, Torres and Acosta cleared their first major hurdle: They passed all three of the state board exams.

Now, though, they face an even more daunting challenge: winning the fierce competition to get into a residency program.

“We have finished all of our tests, and we were thinking that would be the hard part of the process,” Acosta said. “But we found out that we have another hard part, trying to get into residency.”

Of some 250 medical professionals who have participated in the association’s program, only about 20 doctors have stepped up to residency programs so far, Nguyagwa said. About 20 nurses have gone all of the way to nursing jobs, he said. A few dentists, pharmacists and professionals in other medical specialties also have gone through the program and landed jobs.

Torres and Adhikari got a lucky break. They won two of the four slots this year in the Preparation for Residency Program Nicholson directs at the U of M. For seven months they will get intensive training on the health-care system,  including hands-on work helping other doctors in clinics and hospitals much like the training given to advanced medical school students.

“We try to give them enough clinical training so they can be competitive in the residency match,” Nicholson said.

All three Somali doctors who went through the program last year won residency slots. So prospects are bright for this year’s class.

More tentative are the future prospects for other foreign-trained doctors. The state had funded the $150,000 program, but lawmakers cut the funding during 2011 budget negotiations. U of M President Eric Kaler came up with the money to keep the program running, but the loss of state funding makes it more vulnerable.

Nicholson argues that the program is a bargain for Minnesota. The cost of putting a future doctor through medical school and related training runs at least $300,000, he said.

For $150,000, four foreign-trained doctors — who have managed to pass the medical board exams, often with help from the Association — can be prepared in just a few months to compete for residency slots.

New challenges
Funding remains a struggle for the association too. Holder continues to cobble together grants and appropriations from foundations and other sources such as the U.S. Department of Labor and the U.S. Office of Refugee Resettlement.

Meanwhile, Holder and Nguyagwa have moved on to new challenges while also keeping a finger in the association’s work.

Holder is the executive director of Women’s Initiative for Self Empowerment, a nonprofit aiming to help immigrant women and girls succeed economically.

Nguyagwa recently finished studying under a Bush Fellowship at the U of M’s Humphrey School,  and now he is starting a six-month fellowship in bilingual communication at Georgetown University in Washington, D.C.

Mimi Oo
MinnPost/Sharon Schmickle
Mimi Oo

Meanwhile Mimi Oo is the association’s new program coordinator. Oo, 58, completed medical school in Burma (also known as Myanmar.) She practiced there for years and worked for five years in Uganda as a volunteer physician with U.N. programs.

Oo said she passed all of the required exams to practice medicine in Minnesota and also gained clinical experience working as a phlebotomist and a medical interpreter. But she never landed a residency.

So she understands her challenges as she replaces Nguyagwa.

“His shoes are too big to fill,” Oo said. “He did everything. He did advocacy. He did mentor support. He did peer support programs. He wrote grants. He went to visit Duluth, Crookston, all of the outreaches.  He has been everywhere.”

Especially needed by immigrants
Still, she is motivated by the conviction that Minnesota’s growing immigrant population needs the foreign-trained doctors. Take the local Burmese community, which Oo knows very well.

“Let’s say that a Burmese patient has high blood pressure,” Oo said. “A regular doctor will ask through an interpreter, ‘Have you been adding salt to your diet?’ Through the interpreter, the patient would answer, ‘No, I haven’t done that.’

With a Burmese doctor the dialogue would be more informed, beginning with the question, “Have you been eating fried fish paste?” The typical Burmese patient would answer, “Of course, this is my daily diet!”

There’s the problem. Every Burmese-trained physician knows that fish paste is laden with salt.

“These are some of the nuances of being from the culture,” Oo said. “It makes a huge impact.”

Despite the barriers, Oo insists that the work started by Holder and Nguyagwa will continue because resourceful immigrants will find a way to succeed.

“They went through all kinds of things to come to the United States, through all kinds of challenges and they survived,” she said. “These are resilient people!”

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