Shoshana Akabas | Longreads | October 2021 | 16 minutes (4,762 words)
*Haben Araya was working in the local hospital when a farmer came in, bleeding from his gums. He was suffering from a snakebite — a case she’d seen many times.
*At the request of the doctors involved, some names have been changed.
Before Araya sought asylum in the United States, before she helplessly watched the COVID-19 pandemic tear across the country, and before she learned about what doctors must go through to relicense in America, she worked as one of a handful of physicians on staff at a local hospital in her home country of Eritrea. She was a general practitioner, responsible for everything from pediatric preventative medicine to minor surgeries and gynecology. She served as the regional appointed physician for malaria case management and the hospital’s Director for Tuberculosis Control. If a patient needed to be transferred to another hospital, she had to write the referral. Call the ambulance. Make sure the ambulance has enough gas. Find someone to fill up the tank.
Snakebite cases were heartbreaking for Araya because she knew the medication was prohibitively expensive: 840 Eritrean Nakfa for a single vial (about 56 USD). Sometimes four or five vials were required, costing more than many farmers would earn in a year.
The hospital insisted on taking some sort of collateral until the bill was paid, but Araya knew the farmers were good for the money. She also knew that they would likely sell their goats or sheep — whatever animals they relied on for their livelihoods — to pay for the treatment. And then, she knew, they and their children would return in a few months’ time with severe cases of malnutrition and a host of consequent health issues.
A nearby military clinic, where there was no on-site physician, had a stock of antivenom. In exchange for a free supply for her patients, Araya told the administrator of the unit that she would provide medical consultation and training. It was not a perfect solution, Araya admits, but her job was to do anything she could for her patients. “We have to do our best with what we know,” she says. “Every day we had to be more than a doctor.”
Doctors trained in resource-limited environments possess a unique skill set. They’re adaptable, creative, and work well under pressure. Yet, upon arriving in the U.S., internationally trained physicians like Araya must go through a licensing process so arduous it can take nearly ten years to complete. There are currently an estimated 165,000 internationally trained medical professionals living in the United States and underutilizing their skills. Many, like Araya, are sitting on crisis management experience the United States never thought they would need — until the pandemic hit.
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Eritrea has a single medical school: the Orotta College of Medicine and Health Sciences, offering a six-year medical program. With only 30 to 40 spots in each graduating class, the nationwide competition was fierce. “When I applied to medical school, my dad always tried to impress on me that I need to have Plan B and Plan C,” says Lily Yemane, an expat Eritrean physician like Araya. But she couldn’t think of any other job she wanted to do.
In the United States, the pandemic forced many doctors who had never experienced shortages to make life-or-death choices about who would be given oxygen, but for Araya and Yemane, that kind of challenge was part of their regular work as physicians. “You have an idea of how a certain patient can be helped, but you don’t have the resources,” explains Yemane. “Two or three patients need a medication, and you have to decide who to give it to.” With only one or two ambulances per hospital, she often fought to convince the administration to deploy their ambulance for her patients.
Resource scarcity wasn’t the only issue. Living under the oppressive regime in Eritrea bled into every aspect of their personal and professional lives. “We don’t choose where we work, we don’t negotiate our salaries,” says Araya. “The government, basically they put our names in a fishbowl.”
Since President Isais Afwerki came to power following the country’s independence in 1993, freedom has been stifled. Afwerki’s extrajudicial executions, imprisonment of journalists and religious minorities, indefinite forced labor sentences, and other human rights violations have been documented by the United Nations Human Rights Council. Reporters Without Borders, on its World Press Freedom Index this year, ranked Eritrea last, below North Korea. There have been no presidential elections held in the country’s 28-year history. “ … You don’t get any say, you don’t vote. We’ve never voted in our entire life,” says Yemane.
When political prisoners were brought to the hospital for care — often for tuberculosis or scabies, the result of years in captivity — doctors were forced to defer to a system they vehemently opposed. Some prisoners were journalists; others had been caught at the border, trying to flee the country. “You almost never ask why,” says Yemane. “You don’t want to know.”
Each time a prisoner was brought for treatment, Yemane had to convince the guards to admit the patient to the hospital for necessary care, raising suspicions that she was on the prisoner’s side. Except once: Yemane supervised the care of a prisoner with kidney failure. When she went to check on him in the recovery facility, she was surprised to find the patient with his family, and the guards nowhere to be found. “He was free,” she says, “but they only let him go because they thought he was dying.”
There was no single moment that pushed Yemane or Araya to leave and follow their family and friends who had already fled to the US. Instead, the burden of oppression and persecution simply grew until they felt they had no choice. “My rights as a human being were being violated,” says Araya. “I did not have the freedom — that basic, basic freedom … we all deserve as human beings.”
Yemane did not arrive in the United States naive to American culture or to the challenge ahead. She’d read plenty of English literature and loved watching Oscar-nominated movies, from My Fair Lady to La La Land. But still, the culture shock was real. While waiting the nine months for her work permit to be approved, she lived with a family member and took an anatomy course at the local public college, working towards a physician assistant’s degree in case she couldn’t relicense. Eager to resume medical practice, she also began volunteering at a free clinic, which helped her to feel more at home as she gradually met more like-minded people.
Reporters Without Borders, on its World Press Freedom Index this year, ranked Eritrea last, below North Korea. There have been no presidential elections held in the country’s 28-year history.
When Araya reached the United States the following year, more than a dozen Eritrean doctors like Yemane — who’d fled in the months before her — warned her of the difficult road ahead. She’d have to have her credentials verified before she could sit for the three intensive U.S. medical licensing exams (USMLE) and apply for a residency program to repeat her training — the last step before finally being able to practice on her own.
For most refugees arriving with few resources, the financial cost — of translating educational records into English, covering the exam fees (nearly $1,000 each), and working a clinical internship (often unpaid) to help get a residency — is prohibitive. And the Eritrean doctors were struggling to get past the very first step in the process. For their primary source verification, authorized representatives from the Eritrean medical school would need to confirm that their documents, including their diploma and transcript, were authentic.
They’d contacted the Educational Commission for Foreign Medical Graduates (ECFMG), a non-governmental, non-profit agency, responsible for primary source verification. Of roughly 3,500 operational institutions in the World Directory of Medical Schools, ECFMG accepts credentials from approximately three-quarters — including the medical school in Eritrea. But when Araya and Yemane’s colleagues applied for verification, the Eritrean administrators wouldn’t respond to ECFMG’s inquiries.
The medical school and placement system in Eritrea, like many countries, is controlled by the government, which has the power to withhold the records of anyone they don’t want to assist. “In the eyes of the government,” says Yemane, “we are traitors — which is not true. We served our country when we were there. I worked with very little pay, like everybody else in the country, for four years, outside of my hometown. And we did serve the people. We did our best. But the government was not understanding of that. So when we left, we were considered traitors.”
Kara Oleyn, Vice President for Programs and Services at ECFMG, was assigned to their case. ECFMG sees 20,000 applications each year, and Oleyn was no stranger to verification challenges. When ISIS infiltrated Iraq and medical school officials fled to the south, Oleyn’s team worked with the Iraqi Ministry of Health to track them down, so they could provide verification for their former students. In Crimea, where both the Russian and Ukrainian governments claimed the medical university, they had to determine who was actually authorized to verify credentials. “We do need to assure the public that the individuals who are going to be laying hands on them have the appropriate credentials,” says Oleyn, “and primary source verification is a big part of that.”
But Araya’s and Yemane’s cases — and the cases of their Eritrean colleagues — stumped Oleyn. “There was absolutely no information coming out of Eritrea,” she says.
Araya and her peers were devastated. “The fact that the government I left was able to affect me here — it was just heartbreaking,” says Araya. “America, they gave me protection to stay here, but the [Eritrean] government was able to retaliate and hold me hostage, even when I’m here.”
In rare cases where verification couldn’t be obtained — often for political asylees — the ECFMG used an alternate process: having three U.S.-licensed physicians who attended the same international school swear on their medical license that they have personal knowledge that the individual graduated from medical school. Unfortunately, the Eritrean medical school, founded less than 20 years ago, had no prior graduates working in the United States to provide testimony.
Oleyn’s three-person team relentlessly contacted any sources they thought might be able to share information. “We were trying to triangulate exams that we knew they took in Sudan with Sudanese officials, and we couldn’t get anywhere,” she says. Even the US Department of State couldn’t offer any contacts in Eritrea besides those already refusing to cooperate. Instead, the State Department confirmed what she recalled the Eritrean applicants had already told her: “They’re not going to reply to you, because they don’t want their physicians … their young, bright, educated people to leave their country.”
Yemane and Araya’s feeling of helplessness intensified as the pandemic rolled through their new homeland, and they watched as the news quickly became saturated with reports of hospitals running out of beds and doctors to care for COVID patients. When Eritrea went into lockdown, they feared for their friends and family left behind. Yemane would close her eyes and remember the limited number of beds in the hospital’s ICU, imagining them all filled. The staff was already underpaid and overworked before the pandemic.
“In a perfect world, when this happens, what do you do? You just go home and you help, and then you come back,” says Yemane. “We could not go back home, even to help, even to contribute.” And in America, she couldn’t help either. “… Imagine sitting with the capacity to do something but not being able to do anything … What was the whole point of your training if you cannot do something, even in a pandemic?”
Many internationally trained doctors have valuable experience working in the thick of SARS and Ebola epidemics, conflict zones, and other limited-resource conditions — not unlike the conditions faced by hospitals across the United States, as doctors scrambled for personal protective equipment. “When you have a shortage in supplies all the time, you get creative,” Yemane explains. “When we didn’t have ventilators, we could make CPAPs out of things that you can access at the hospital. So we have that kind of mindset.”
Jina Krause-Vilmar, the president and CEO of Upwardly Global, a nonprofit organization that provides career services to immigrants and refugees (including several interviewed for this story), says that, despite knowing the risks of COVID-19, their clients were anxious to help and “in tears about the idea that they were standing on the sidelines at a time when their communities were suffering.”
Unable to assist medical efforts directly, Yemane volunteered for a mutual aid society to help with cooking and delivering food to a local homeless encampment, but she wished she could do more. At the height of the pandemic, “that’s when it was most painful,” she says. “You see the hospitals running low on supplies, on skill[ed workers], and you’re sitting at home doing nothing when you could have been out there helping people.”
Yemane would close her eyes and remember the limited number of beds in the hospital’s ICU, imagining them all filled.
In a few select states, desperation finally bred change, and internationally trained physicians were given the opportunity to contribute. New York (home to roughly 13,000 foreign-trained medical professionals not able to make full use of their skills) joined New Jersey, Massachusetts, Nevada, and Colorado in adapting licensing guidelines to allow foreign-trained physicians to help with COVID efforts at various levels — but with limited success.
For some, the application was too difficult. Upwardly Global heard that in one state Russian applicants were deterred because the drop-down menu on the online application accidentally omitted “Russia” as an option for country of origin. Some, like Yemane, applied to the NJ licensing program but never heard back.
“These were emergency policies that were designed and implemented at a time of unprecedented need and at a time when states were trying to mount a response to a public health crisis like no other,” says Jacki Esposito, director of U.S. Policy and Advocacy for World Education Services Global Talent Bridge, a non-profit dedicated to helping international students, immigrants, and refugees achieve their educational and career goals. “So just by virtue of the fact that they were designed and implemented very quickly, there wasn’t the time and the space to consult all of the various stakeholders that would be consulted in a permanent reform process.”
For example, according to Esposito, some states require applicants to have active, valid licenses in another country, but many people — refugees especially — let their licenses lapse to avoid yearly fees and continuing education requirements. Esposito says the application could have required that a foreign license was in good standing when it was last active to accomplish the same goal — of weeding out those applicants with disciplinary actions on their record. “It really was a mix of getting the eligibility requirements right so that they maintain health and safety standards, but at the same time are accessible for applicants,” says Esposito. “Eligibility requirements must be workable for these policies to be effective.”
Without the time to be more intentional about the design of the application process, inform employers about the policy, or conduct outreach to applicants, the opportunity went underutilized. By the end of 2020, the New Jersey Board of Medical Examiners, which operated the most robust program for applicants without residency experience, had received approximately 1,100 applications for temporary medical licenses, but, according to a spokesperson at the New Jersey Division of Consumer Affairs, they issued emergency licenses to only 35 individuals. And according to Gothamist, not all who received emergency licenses were able to secure positions. Many applicants who were eligible for similar programs across the country didn’t know where to look for jobs, and hospitals weren’t sure they were allowed to accept internationally trained applicants — or just thought it was easier to not employ them.
“When push came to shove, the hospitals would rather repurpose a plastic surgeon,” says Tamar Frolichstein-Appel, a senior employment services associate at Upwardly Global, who believes better outcomes could be achieved if healthcare employers, legislators, and NGOs work in partnership. Without buy-in from employers who are willing to hire from this talent pool, a license doesn’t make much of a difference. “It’s a missed opportunity that we have not, as a country, leveraged the immense talent that immigrant and refugee doctors and other healthcare workers offer,” says Esposito.
Amid the crisis, a door was cracked open for a select few. But, by and large, doctors like Araya and Yemane watched the pandemic unfold, stuck outside of a system they desperately wanted to be part of. “We got so antsy to do something,” Yemane says. “It’s a privilege to be able to help in that time, and we didn’t have that.”
As more time passed without any news of progress from ECFMG, the persistent uncertainty began to take a toll on the Eritrean doctors stuck in limbo. “A few of us went back to medical school again. But to go to medical school twice in one lifetime — it’s a lot to ask,” says Yemane.
After fleeing Eritrea, another doctor, Abraham Solomon, chose this option to avoid being at the mercy of a stalled bureaucratic process. But he couldn’t simply repeat medical school; he had to go back even further and complete up to 90 credits of undergraduate pre-med requirements before even taking the Medical College Admission Test (MCAT). As he sat through freshman seminars for the second time in his life, he had a strong sense that this situation wasn’t fair, but he had to make peace with it. “What [I] had to do was more important than getting lost in the emotions,” says Solomon, who worked in customer service to pay for school. “At that point, you understand this is something you can’t control.”
Mohamed Khalif, who left Somalia as a refugee when he was two years old, moved around the world with his family before graduating medical school in China. While studying for the USMLE in Washington State, he worked as a security guard and then took night shifts at a pie factory so he could volunteer at a medical clinic. Khalif has valuable skills and is fluent in five languages, including Urdu and Mandarin, but even after he passed the USMLE he failed to match with a residency program. The screening for residency programs filters out candidates without “hands-on” clinical experience in the United States: few applicants can afford unpaid internships, and few institutions are willing to take them on over U.S. medical students. The applications cost Khalif more than $6,000 each year, in addition to flights and hotels for interviews. After four years, he decided he had to go in another direction.
As the founder of the nonprofit Washington Academy for International Medical Graduates (WAIMG), he now advocates for those who face the same challenges and offers professional development opportunities through his organization. Through this work, he met folks with similar stories, like a Japanese neurosurgeon who married an American and moved to the U.S., but, even after passing the USMLE, was still working at Starbucks because she couldn’t match into a residency program. Khalif’s organization hired her for a job that would count as “hands-on” clinical experience to improve her prospects.
“Once she found this job,” says Khalif, “she actually cried. And I felt that. Because that’s what I’ve been through — those kinds of odd jobs — and I cried with her.” These stories keep him hopeful, even though he’s not able to practice: the fact that he’s making it possible for so many others.
The matching process is a major concern for Araya, Yemane, and their peers — not having their official transcripts or diplomas will likely pose problems during the difficult process of applying to residencies — once they even reach that stage. This year, only 55 percent of immigrant international medical graduates who applied for residency were matched to first-year positions, compared to 93 percent of U.S. graduates.
And every year Araya and Yemane have spent fighting for the right to even sit the exams has cost them: The more time that passes after a candidate’s graduation year, the harder it can be to secure a residency match.
“When you only consider somebody’s graduating year as a criteria and not know the story behind that, it hurts a lot of people. It hurts a lot of people who are really passionate,” says Araya. “To come here to fight for all these years to go back into your profession — that tells a lot about the persistence and the passion that person has for medicine.”
Amid the crisis, a door was cracked open for a select few. But, by and large, doctors like Araya and Yemane watched the pandemic unfold, stuck outside of a system they desperately wanted to be part of.
Khalif began to look for a solution that wouldn’t require physicians to repeat their entire residency. “Legislators did not know about this match process and this residency process,” says Khalif. “They thought people could apply for residency through Indeed Job Search or something.”
Members from Khalif’s non-profit met with legislators and eventually started gaining traction. “COVID really changed people’s minds,” says Khalif, and in May 2021, Washington Governor Jay Inslee signed into law SHB 1129, which allows limited licenses to be granted to internationally trained doctors in Washington who have completed their USMLE, without requiring residency to be repeated in the U.S. “Once you pass all your exams now, you don’t have to settle for an odd job, or leave the profession like I did,” says Khalif. “You can qualify for a license and work under the supervision of a physician, and you can take care of patients.”
The bill was overwhelmingly supported on both sides. Republican representative Mary Dye says that her small county of Garfield, with only a handful of doctors, has benefited from internationally trained physicians from Bangladesh and South Korea, who can work without the equipment, facilities, and large medical teams that most U.S. doctors rely on. “In rural America, we need people that have different experiences,” Dye explained. “We’re grateful to have … people that are capable of serving in these remote locations, under challenging conditions, with lots of limitations, and still provide wonderful medical care for our community.”
From the rural healthcare crisis to expanding medical access for at-risk populations, advocates believe internationally trained physicians could be part of the solution if given the opportunity. “I think they have a huge role to play in terms of health equity access, because of that cultural language fluency,” says Krause-Vilmar.
“We need to re-envision what the process is for licensure for doctors in the United States,” says Esposito, “so that we are not leaving out people who have 20 years of experience in a field where we know that we need more doctors.”
Without any change in legislation in California, the current residency hurdles are still daunting for Araya and Yemane, who hope that, when the time comes, institutions will consider their circumstances and give them a chance to prove themselves. “We are all a loss for our country,” Araya says. “I hope we’re not a loss here.”
One night, more than a year into the investigation process, Oleyn was working late in her Philadelphia office when she received a call from one of the Eritrean applicants. She detailed everything her team had tried — most recently, reaching out to the medical school in Cuba that had a partnership with the Eritrean medical school. But it was another dead end.
“Anything you can think of,” she asked on the phone that night. Anything at all.
In an attempt to leave no stone unturned, the applicants submitted lists of people they’d come into contact with during medical school — in the hope of providing a useful connection. As Oleyn’s team searched for leads through the lists of names, they found that one was a dean at a U.S. medical school. It turned out that a small number of U.S. physicians — faculty members of American medical schools like George Washington University — helped establish the school in Eritrea. The connection provided a glimmer of hope after months of coming up empty-handed.
A caseworker from Oleyn’s team contacted the dean; he didn’t remember the specific students but put them in touch with other American faculty members who had taught or helped design the post-graduate training curriculum in Eritrea. Oleyn’s team asked those physicians to verify the information about the applicants: the courses they took, which textbooks were used, and their graduation dates. They responded enthusiastically about the qualifications of each applicant and eagerly asked how they could help.
The alternate form of verification — with all the supporting evidence they had amassed — was presented to the ECFMG’s board of trustees, which finally granted approval in summer 2020. Araya and Yemane could move forward to the exam stage. When Yemane heard the news, she felt like she’d finally gotten her life back. “There was a time when I was too scared to be hopeful about that because I didn’t want to be disappointed,” she says.
Solomon had just finished a year of intro courses — Biology, Chemistry, and Physics — when the decision was released. He no longer had to repeat the rest of the prerequisite courses and medical school, and he was thankful to finally have some control over the next steps. “This is a challenge I can overcome,” he says. “An exam is just an exam. You study. You prepare.”
“It’s a good thing that we’re doing this exam,” Yemane says. “It’s a good way to revisit the basic sciences and to familiarize ourselves with what’s most important and most common in this country.”
The Eritrean physicians continue to stay in touch through their Whatsapp group, meeting occasionally, sharing job opportunities, and cheering each other on. Araya says she won’t stop rooting for their success. “Passing the exam, getting matched [with a residency program] has become more than even being a doctor: Just proving that the government back home, the school — whoever could not give us our certificates, credentials — that actually, there is justice in the world, and they could not dictate our professional pathways.”
This year, only 55 percent of immigrant international medical graduates who applied for residency were matched to first-year positions, compared to 93 percent of U.S. graduates.
In a thank you note Oleyn received an Eritrean physician wrote: “This shall also afford every graduate the privilege to revisit his/her oath to humanity, to summon his/her medical expertise, and to engage hereafter in the honored service of the people of the United States of America.”
It remains the most gratifying case Oleyn has seen in her 22 years at ECFMG.
On a warm Thursday in June 2021, Yemane traveled to San Jose to take her first exam. She hadn’t slept well the night before. Kept awake by nerves, she’d scrolled through Reddit, where other nervous exam-takers shared their anxieties. But in the morning, she pretended she’d had the best sleep of her life. “I think that worked,” she laughs. “I think I fooled my brain.”
The test center was familiar because she’d paid $75 to take a practice exam there earlier that week, but it was nerve-wracking all the same. “There was a lot of pressure on me, because I’m one of the first people taking the exam from my country,” she says. “And we begged for three years for this opportunity.”
She reminded herself that she was prepared. She’d done over 7,000 practice questions. She thought about a text her friend sent, telling her that the test outcome would not change her identity. She imagined her father and mother telling her, “You were created for this.”
When she finished the eight-hour exam, a sense of relief washed over her. This was the hardest test for her; the next one focuses on clinical skills, and she hopes to sit for it in spring 2022. After that, she will take the third and final test. The next challenge — applying for residencies — will be the final step in the long and expensive licensing process.
For now, though, she’s taking one step at a time. As she anxiously awaits the results, she knows that even if she doesn’t get the score she’s hoping for, she was brave just to take the exam after everything she’s been through. “That’s what I’m doing right now,” she says. “I’m celebrating the bravery.”
Shoshana Akabas is a writer and teacher based in New York. She primarily writes fiction and reports on refugee policy and issues of forced migration.
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