Keywords

Introduction

The southeast region of the Latino Medical Student Association (LMSA Southeast) encompasses a broad and large geographic area consisting of medical schools in the states of Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia, as well as the Commonwealth of Puerto Rico and the Caribbean islands. This represents a vast territory of approximately 440,000 square miles of land [1], with a diverse array of local and regional cultures, as well as, ethnicities and political views.

The largest populations of individuals identifying as Latino in this vast territory are largely concentrated in Puerto Rico and rural areas or around large metropolitan areas in the states of Virginia, Georgia, North Carolina, and Florida [1]. Notable areas in the region with large concentrations of Latino populations include Miami-Ft. Lauderdale, Tampa, Orlando, Jacksonville, Atlanta, and Raleigh-Durham [2]. The pioneers and founders of these populations in the region have represented the full spectrum of social, political, and economic classes. Some areas and populations owe their roots to factories and migrant farmworkers while others were founded by skilled laborers and highly educated professionals [1]. The Latin American nationalities and ethnicities represented in particular states and metropolitan areas largely reflect the history of U.S. immigration policies and Latin American geopolitical conflicts. As in other places in the United States, Latinos in the southeast have fled social and economic strife in their home countries, often seeking refuge from violence and political oppression. In turn, these brave men and women have brought an increasingly diverse array of Latin American cultures to the southeastern United States that has enriched the greater culture of the region.

The demographic history of Latinos in the region has paralleled the growth of LMSA Southeast. However, the increasing density of Latino populations in the southeast has not kept pace with the diversity of medical schools in the region. At a regional level, with the exception of Puerto Rico, Latinos continue to be severely underrepresented in medical education and are often dispersed in small numbers at individual medical schools throughout the country [3]. Accordingly, many medical schools in the southeast suffer from very small enrollments of Latino students, from which it was and continues to be difficult to create or sustain a thriving LMSA chapter. Even at some schools in the southeast with larger enrollments of Latinos, past leaders have noted challenges in organizing strong LMSA chapters, because some Latino students did not readily identify with their ethnic background or realize the potential benefits of involvement in LMSA. This has represented and continues to be a unique challenge to the growth of LMSA in the southeast region as compared to other regions where there has either been a larger, critical mass of Latino students, an inherently majority-minority population or a more robust history of Latino medical student organizations.

Historical Background

The story of LMSA Southeast and Latinos in the region is unquestionably tied to its geographic proximity to Latin America. Accordingly, its history is marked by the lasting impact of political upheaval, violence, economic disruption, and natural disasters in various Latin American countries and Puerto Rico. Presently, Latinos in the southeast identify with many different countries of origin. The most significant waves of migration and immigration to the region have been dominated by socioeconomic conditions and events in Cuba, Puerto Rico, Colombia, Venezuela, Argentina, El Salvador, Nicaragua, Honduras, Dominican Republic, and Mexico.

In telling the history of Latinos in the Southeast, the significance and contribution of the state of Florida and South Florida cannot be understated. The state of Florida has the third-largest Latino population in the country and the largest in the southeast [1]. In fact, there are more Latinos in Florida than in Puerto Rico. The early history of Latinos in Florida was largely shaped by the events and consequences of the Cuban Revolution. Undoubtedly, the overthrowing of Fulgencio Batista by Fidel Castro in 1959 and the resulting social, political, and economic upheaval that ensued for decades thereafter has impacted the demographics and politics of Florida for the last 60 years. Over the course of six decades, over 1.3 million Cubans have migrated to the United States in five major waves. It is on the backdrop of this history that South Florida’s emergence as the “Gateway to the Americas” is predicated.

Before 1960, South Florida had a rather small Latino community. However, this changed dramatically with an influx of approximately 508,700 Cubans to the United States, in just over one decade from 1959 to 1973. A large majority of these political exiles and refugees settled in Miami and the surrounding communities, forever changing the character and culture of the city and surrounding South Florida region as well as the politics regarding immigration to the State of Florida. During the first wave of Cuban migration, over 14,000 children fled Cuba as part of a U.S. State Department project named Operation Peter Pan, from 1960 to 1962 [4]. These unaccompanied minors were airlifted to Miami, Florida. Upon arrival, they were placed in the care of Catholic Charities until they could be placed in foster homes or reunited with family members.

The 1960s was also an important decade of national immigration policy. In 1965, President Lyndon B. Johnson signed the Immigration and Nationality Act into law. This law abolished the immigration quota system and shifted the focus of immigration policy toward reuniting families. Additionally, this new policy also focused on bringing in skilled and educated workers, which allowed many physicians trained in other countries, including Latin America, a new pathway within the U.S. immigration process. One source has documented that at the time, approximately 388 physicians trained in Latin America immigrated to the United States, a tally that did not include Cuban physicians [4]. It is more difficult to quantify the number of Cuban doctors who immigrated during this time. However, based on the efforts of certain local institutions such as the University of Miami, which established an Office of International Medical Education, it is clear there was a significant number of Cuban physicians who also immigrated and sought to practice in the United States.

Over the past 60 years, a myriad of political events and natural disasters throughout both Central America and South America have fueled immigration to the Southeast. Additionally, the politics, as well as the immigration and foreign policies of the United States, has also played a significant role. One such example is the history of Operation Condor (1968–1989), which was a U.S.-financed campaign involving several South American countries and dictatorships that punished political dissidents, social activists, trade unionists, and religious clergy [5]. Initially, Chile, Argentina, Bolivia, Brazil, Paraguay, and Uruguay were involved in this plan, and Peru, Colombia, and Venezuela joined later on as the project progressed. It is reported that thousands were raped, murdered, or “disappeared” in these countries and that this violence caused many to flee to the United States to escape authoritarian oppression [5].

The 1980s and 90 s were decades of a number of important immigration events. One notable event was the Mariel exodus and boatlift, a humanitarian crisis brought on by Fidel Castro’s actions after approximately 10,000 Cubans flooded foreign embassies on the island, seeking political asylum. As a result, Castro proclaimed the port of Mariel open to anyone wishing to leave the country. The crisis lasted from April to October 1980, with approximately 125,000 Cubans leaving the island on boats and ultimately seeking political asylum in Florida [6]. However, a much larger influx of Latino immigrants during the 1980s resulted from civil wars in El Salvador, Guatemala, and Nicaragua. The violence and economic strife caused by these wars drove thousands of immigrants to seek refuge in the United States. In a single decade from 1980 to 1990, the population of Central Americans in the United States tripled, with many taking residences in the Southeastern states, chiefly Florida and Virginia. Later in 1994, the Cuban balsero crisis brought approximately 30,900 Cubans to the U.S. and punctuated years of countless lives lost at sea while attempting to cross the ocean in homemade rafts. As a result, the Clinton administration negotiated with the Castro regime and established new policies including the “wet foot - dry foot” policy for those apprehended by border patrol or Coast Guard agents, in addition to a yearly legal immigration lottery system organized by the U.S. State Department.

Another contributing factor to immigration has been the destruction, displacement, and economic turmoil caused by natural disasters such as hurricanes. Although hurricanes are a common occurrence for the Caribbean islands, Central America, and the coastal southeastern United States, the damage caused by large and powerful hurricanes often causes individuals to abandon their homes and relocate. One such storm was Hurricane Mitch in 1998, which devastated the countries of Nicaragua and Honduras, resulting in a large number of refugees, a number of which took up residence in Florida. Similarly, Hurricane Maria in 2017 devastated Puerto Rico, causing over 400,000 individuals to move out of the island, with the largest amount, 43%, relocating to Florida [7].

As one might imagine, the events, conditions, and circumstances prompting immigration as well as the process itself do not come without significant health repercussions. Post-traumatic stress disorder related to the immigration process was not uncommon [8]. Individuals who have experienced trauma may also exhibit distrust of medical providers and other officials [5]. Other significant related health concerns include substance use and its many medical complications [6, 8]. Lastly, many immigrants face economic hardship once arriving in the United States [6], a contributing factor to the development of health disparities.

An additional source of stress and fuel for health disparities is the labyrinth of immigration policies that govern legal status in the United States. These policies often divide and discriminate against Latinos based on national origin and the circumstances underlying their immigration. The consequences of these policies have resulted in divided families and communities labeled by their “status” and afforded different access to full participation in society depending on whether they are legal permanent residents, undocumented, refugees, asylum seekers, or temporary protected status [9].

Overall, the southeast has experienced consistent and rapid growth of the Latino community. This history of immigration and the events surrounding them are the context in which the students of the LMSA were raised and planted the seeds for Latinos in medicine. In one way or another, every member of the LMSA community has been affected by immigration and immigration policies, be it directly, within their own family, or in the communities that they serve.

Putting the Pieces Together: The Early Years (1987–2010)

The precursor to LMSA-Southeast was the National Network of Latino American Medical Students (NNLAMS) whose origins date to a national meeting of regional medical student leaders in Chicago in 1987 but was later formally organized in 1999. In 2003, national records indicate that the southeast region adopted the NNLAMS name. However, details of the role of leaders from the southeast during this time have been lost to time, but it is loosely known from oral history that there were active student groups in the region at the time and possibly a number of decades earlier. Under NNLAMS, regional groups acted collaboratively, yet functioned largely independently with limited communication and structure. As such, many of the details of the organizational and regional activities during these early years have also been lost to history. Nonetheless, it is known that a number of individual medical student organizations at several medical schools, who identified as either Hispanic or Latino, were active and functional in the region, and that a number of these organizations predated the creation of either NNLAMS or LMSA. For example, two schools in Florida, the University of Miami and the University of Florida had chapters that went by the name of the Hispanic American Medical Student Association (HAMSA). Conversely, the local chapter at the University of South Florida utilized the name Latino American Medical Student Association (LAMSA), and later the Hispanic Medical Student Association (HMSA). Some institutions had different names altogether, whose focus was beyond that of students, such as Edward Via College of Medicine in Virginia, which preferred the name Hispanic Community Medical Outreach (HCMO). There were also groups outside of the United States, such as at Ross University in Dominica, who used the name Organization of Latin American Students (OLAS). “For whatever reason, it was hard getting the students to buy into the LMSA agenda, and they chose to be called the Association of Latino Medical Students (ALMS),” Dr. Jose Rodriguez, former Chapter Advisor at Florida State University explained. “FSU’s chapter was still going by ‘ALMS’ at their campus by the time I moved [in 2016].”

Furthermore, Dr. Rodriguez recounted the motivation behind starting ALMS at that time. “Initially, the group was part of SNMA (Student National Medical Association), but they felt that organization wasn’t fully meeting their needs.” This sentiment was a common theme of the formation of many chapters of LMSA (and similar groups) in the Southeast region.

The success of the group at FSU was especially notable as the medical school was new, yet still had sufficient interest to support the new organization. Dr. Rodriguez remained the chapter advisor throughout his time working at FSU. During that period, he notes the university also benefited from starting an LMSA chapter, both in terms of recruiting Latino students and being recognized at a national level as FSU was ranked as one of the Top 10 medical schools for Latinos for 6 years.

During this same time period, a separate organized medicine movement outside of medical schools began forming at the professional level, organized by Latino physician leaders on a regional and national stage. Dr. Onelia Lage, a chapter advisor of the student group at the University of Miami, recalls attending the southern regional conference call of the National Hispanic Medical Association (NHMA) in 1994. Dr. Lage noted, “It’s about creating opportunities...The way I see it, I push so that others behind me can have it easier and have more room to grow professionally in academia.” NHMA would later serve to support NNLAMS’ first national conference in 2006 under a joint collaboration with NHMA.

As the region began to take on a stronger regional structure, facilitating face-to-face meetings and improving collaboration on a national level became a greater priority. Most notably, in 2005 the southeast region hosted the Garcia Leadership Seminar (GLAS) at Duke University School of Medicine. GLAS was an important annual event that brought together Latino student leaders from across the nation. This was the first time that a major national event was hosted in the southeast region. Duke University was chosen as the host for the event because it had ample resources and was at the time the home institution of Dr. Omar Rashid, former National Coordinator and then-current Southeast Regional Co-director.

However, this time period was not without its challenges. In the spring of 2006, there were reported interpersonal conflicts which resulted in the schism of leadership, resulting in the following 2006–2007 academic year being a lost year of leadership in the Southeast region. As far as it is known, there is no record of a regional executive board on file and no formal regional activities noted. It is likely that local chapters were able to carry on their activities without major impact, but the guiding regional infrastructure was not active. This was followed by a figurative rebirth of the region in 2007, facilitated by the NNLAMS conference in San Antonio, TX. At that meeting, there were approximately 4 students from medical schools representing the southeast region. These students had either been aware of NNLAMS through their undergraduate institutions or had friends from other regions who informed them of the existence of NNLAMS. Two of these students, Aisha Rivera and Mario Nieto, were appointed by the NNLAMS leadership to serve as ad-hoc chairs for the Southeast, and they began rebuilding the region. Dr. Homan-Sandoval notes the constitution at that time stated that representatives must be elected by members of their own region, yet there no other members from the Southeast region present to elect them, thus this rule was exempted in order to appoint the new regional leadership. Dr. Aisha Rivera recalls the meeting as follows:

“I went to the meeting held in San Antonio and that’s where I met other folks involved around the country involved with the organization.” Dr. Rivera noted. “They were so excited to see that there were medical students in the Southeast who were interested in NNLAMS (or I should say LMSA) and we were there, so it was like ‘there’s no one else here, so you’re representing the southeast!”

Soon thereafter the region would return to growth. In 2009, the Southeast hosted its inaugural regional conference at the University of South Florida on February 27–28, 2009. As conference chair and Southeast Co-Director, Annellys Hernandez was instrumental in organizing the first two regional conferences. Despite being a landmark project for the Southeast region, Dr. Annellys Hernandez recalls her experience as a student planning the first Southeast regional conference was not as stressful as one might imagine and was well supported. “We teamed up with our local AHEC [Area Health Education Consortium] to host the conference. They provided monetary support and mentorship, even helping us develop the logo and posters used to promote the event.”

Another significant project embarked on by the Southeast region was an annual medical mission trip to the Dominican Republic, organized by a chapter at the University of South Florida. Dr. Annellys Hernandez recounted that several students from other chapters in the region would join in on this effort, which not only provided a great service opportunity for members but also helped support the clinic by augmenting the time each year during which services could be delivered.

Joining Forces: Continued Growth (2010–2014)

As the region continued to grow, it became more involved with national activities. The region once again hosted GLAS, the 12th Annual Garcia Leadership & Advocacy Seminar on August 12–13, 2011 at Duke University. Topics discussed included managing student debt, occupational risks among farmworkers, and leadership in the public sector. At this time, there was concern about cultural organizations losing their vote in the Medical Student Section of the American Medical Association House of Delegates. At the 2010 Minority Health Summit, leaders of these student groups discussed supporting each other by attending each other’s conferences, forming alliances, and being more collaborative as they shared similar goals and missions. This show of solidarity also helped fortify the pipeline of diversity in medicine as well as address the intersectionality of latinidad.

This period in the history of the Southeast region was one focused on increasing the visibility of the region on a national level as well as strengthening the region internally. Over the next few years, the region was presented with both many opportunities and successes as well as challenges. Miguel Gosalbez, then a medical student at the University of Miami Miller School of Medicine, notes that several organizational issues within the southeast region took some time to resolve during his tenure as regional Co-Director from 2011 to 2013.

When I initially became president, we weren’t fully aware how many chapters we had or how many were active. It was a little disorganized initially, so one of the things we wanted to try while I was there was reaching out to the different chapters, making sure people were involved, and trying to get at least one long-term contact at each one.

During this time in 2012, Dr. Gosalbez was also instrumental in the creation of the LMSA Premedical Latino Undergraduate Society (PLUS) both regionally and nationally. The aim of this effort was to help build a continuum and pipeline of students that unified premedical students, graduate students, and medical student LMSA members. Under this banner, several institutions began forming undergraduate LMSA groups and served as a bridge between the undergraduate experience and medical school. As a student, Dr. Gosalbez was a strong advocate of the program on behalf of the Southeast, and sought allies among members of the LMSA national leadership. He was united in this effort by then Yale MD-PhD student, national leader, and northeast regional co-chair leader, Amanda Lynn Hernandez. Together they championed these efforts at the national level and LMSA PLUS would go on to replace the former program named Premedical Association of Latino Students (PALS). Fittingly, Dr. Gosalbez, who helped coin the term of LMSA PLUS, later served as an LMSA PLUS chapter physician advisor at the University of Florida.

By 2013, the Southeast region continued to have strong leadership and served as host for the 8th annual LMSA National Conference. The event was held as a joint national and regional conference at the University of Miami on March 15–17, 2013. This was the first national conference ever held in the Southeast region. Dr. Elizabeth Homan-Sandoval, who at the time was completing her psychiatry residency at the University of Miami-Jackson Memorial was instrumental in advising the regional leadership and helping to organize the conference. Dr. Homan-Sandoval’s experience as an LMSA alumna and former national leader from the Midwest was a tremendous asset to the burgeoning and rebuilding Southeast region.

In four years from 2010 to 2014, the region experienced strong growth and leadership. After three very well-attended conferences in Miami and one in North Carolina, the executive board focused on continuing to build a strong foundation upon which the Southeast region could continue to grow and flourish. Regional leaders from the time reported they had accumulated a sizable nest egg to provide financial stability for the region. “It was not entirely under our control, but our goal was that when things fall apart when you lose some interest if there’s a year med students are too busy—at least there’s something to fall back on,” explained former Co-Director Dr. Beth Batchelor.

The physician advisor of the region from 2014–2016, Dr. Victor Cueto, also notes the success and strength of the region during this time. “The Southeast leadership truly did a phenomenal job of growing and shepherding the region. As a student leader just a couple of years earlier in the Northeast, I had witnessed my peers in the Southeast such as Annellys Hernandez, Noemi LeFranc, Miguel Gosalbez lay the groundwork that later blossomed under the leadership of Beth Batchelor, Felix Chinea and others. Having grown up in South Florida, I was especially proud to see the region flourish and show LMSA what it has to offer.”

Un Pasito Pa’lante, Un Pasito Pa’tras (2015–2020)

The success of the preceding years had positioned for continued growth and resilience. Chapter membership was strong throughout the region and new chapters in Puerto Rico had been successfully established. This growth set the stage for an ambitious plan to host the 7th Annual LMSA Southeast Regional Conference in Puerto Rico, at San Juan Bautista School of Medicine in March 2015. This was especially noteworthy as it was the first time that a regional conference or any LMSA conference was held outside the contiguous United States.

The main goal of hosting the conference in Puerto Rico was to acknowledge the contribution that Puerto Rican medical schools provide to overall diversity in medicine, as well as increase awareness of Puerto Rican medical students as US graduates. Unfortunately, students from Puerto Rico have been discriminated against and perceived as others, among both peers and residency program directors, who often mistake medical students studying in Puerto Rico for International Medical Graduates (IMGs). Dr. Amnha Zambrano (née Elustra) reported that the conference was very effective in raising awareness of the role of students in Puerto Rico, “Only about 5% of physicians in the US identify as Latino, and of those, half are from or have trained in Puerto Rico. Without Puerto Rican med schools, there would only be 2%. It was important to have the conference in Puerto Rico to say ‘we’re here’” she explained.

The conference was truly a rousing success with regard to visibility and programming. It was very well attended by those on the island of Puerto Rico and those from the mainland. Schools from all over the United States sent students and representatives to the conference. Additionally, the American Association of Medical Colleges (AAMC) also had representatives and leaders in attendance. Even a number of LMSA alumni from various regions attended and participated as speakers. However, the cost of hosting the conference placed a large financial strain on the region. The cost of hosting the conference at a hotel rather than a medical school or other educational institution was a particularly significant expense.

Dr. Cueto recalls that “The students did an amazing job of planning the conference. I remember that Estevan and Amnha were the champions and cheerleaders of the whole effort and they put together a really strong team. The conference was absolutely wonderful all around, the programming was engaging, the venue was beautiful, the students were great hosts, and there were even faculty and alumni in attendance. It was only after the conference that we realized how it had turned out to be really financially tough on the region.”

The subsequent years of 2016 and 2017 were not as strong for the region. In 2017, the number of positions on the regional executive board was reduced from 11 to 7. Marvin Valencia and Lauren Silva, Co-Directors of the Southeast region at that time, cited difficulty filling board positions and decreased participation as the impetus for this change.

In 2019, an effort to increase member engagement resulted in a virtual rather than in-person House of Delegates meeting, which was hosted on September 18, 2019. Over 11 chapters were in attendance. Major business included reviewing requirements for the year, as well as discussing the resolutions to be voted upon at the upcoming Policy Summit in Washington D.C. The concept of a virtual assembly was ultimately successful as it helped overcome two of the main challenges to participation in the region: geographic distance and financial limitations for travel. This new concept has been built on a history of openness and collaboration among student leaders in the region. For instance, Dr. Beth Batchelor noted that during her tenure as a Southeast Co-Director, monthly conference calls hosted by the regional board were open to all LMSA chapter presidents to attend; she stated this helped increase transparency and involvement throughout the region.

During the 2019 academic year, Dr. Elizabeth Homan-Sandoval gained approval from the LMSA national board, Southeast regional board, and the LMSA Physician Faculty Advisory Council to establish a regional Physician Faculty Advisory Council in the Southeast using a parallel framework as the National Faculty Physician Advisory Council. Several physicians in the Southeast region banded together to form the Southeast Faculty Physician Advisory Council, composed of 5 physicians LMSA alumni either working in the Southeast or trained in the region previously. The members of the inaugural board included Dr. Lorena Bonilla, Dr. Claudia Alvarez, Dr. Franklyn Cabrero-Rocha, Dr. Giselle Dutcher, Dr. Elizabeth Batchelor, and Dr. Elizabeth Homan-Sandoval. The main goals of the LMSA Southeast FPAC include increasing continuity within the region, providing opportunities for LMSA alumni to engage with current students, and providing mentorship. As the journey through medical school and matching into residency programs has become more challenging, the Regional FPAC provided hope for additional stability in the region. Additionally, it has become more common for recent alumni to be invited back to regional and national LMSA conferences as speakers and exhibitors, leading to increased interaction with more individuals with institutional memory.

The advisory council had been successful in helping support the region, evidenced by the well-attended conference at Jackson Memorial Health and the election of a full incoming Southeast regional board. Dr. Franklyn Cabrero-Rocha felt it had been rewarding to be part of the Southeast FPACand “though there are definitely times where I might be busy there are several physicians on the advisory council and we all work together to help out.” A precursor to this established advisory board, was the contributions of several individual advisors and alumni, such as Dr. Elizabeth Homan-Sandoval, Dr. Victor Cueto, and Dr. John Paul Sanchez.

Hacia el Futuro: Great Promise (2022 and Beyond)

The rhythm of the southeast region has been an ebb and flow of success and struggle. Several decisions have been made and then reverted over time. The tenor of the region’s growth and the path forward has imbued the composition of the regional student leadership and history of conferences. The locations of conferences and the medical schools represented by the regional student leaders have reflected both the major areas of LHS+ populations in the Southeast as well as the states where LHS+ populations continue to grow. Although 7 of the 11 conferences to date have been held in Florida, with 5 conferences hosted in Miami (Table 3.1), the region has more recently expanded its reach to Georgia, Virginia, North Carolina, and Puerto Rico (Table 3.2). The regional leadership (Table 3.3) has also reflected the growth of chapters in these states and territories. The conference themes also tell the story of the evolution of the region as a whole. The first conference theme—“Sembrando Raíces: A Focus on Latino Health”—illustrates the effort to develop an organizational presence as LMSA Southeast began to take hold. Over time, the conference themes became more specific and discrete, while between 2016 and 2022, the themes have focused on elements of growth, unity and progress. The future of the region will inevitably grow through an ongoing ebb and flow, yet there is hope and evidence that the tide of progress will continue to rise in the Southeast region.

Table 3.1 Regional conference title, date, and host
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Table 3.2 List of States and School Chapters (stand alone or connected) in the LMSA Southeast Region (as of December 2022)
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Table 3.3 List of Southeast Co-Director(s)
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