It all started with a cowboy hat.
Roberto Carmona snuck away from his superiors disguised as a South African cowboy. While working in Namibia, the doctor donned boots and a big hat so he could slip out to the American Embassy, where he asked about qualifying for a special program for Cuban physicians that he hoped would let him defect to the U.S.
Nearly a year later, he was accepted, just days before his overseas job ended. Carmona fled to Tampa, but escaping his homeland turned out to be the easy part.
Carmona and a number of other Cuban physicians who defected while on overseas assignments have confronted a frustrating contradiction in American medicine: They were allowed into the U.S. because they are doctors. But, once here, they cannot treat patients because Cuba has refused to release or certify their academic records.
Without transcripts, it's nearly impossible for the doctors to take the required medical board exams and to get approval from the U.S. group that accredits foreign physicians.
"To come to this country, we have to spend so much time demonstrating to U.S. immigration officials we are doctors and show them so many documents," Carmona said. "Then why is it once we are here, they don't believe us and make it so difficult for us to work in our profession?"
Cuba, which views the defectors as traitors, pays for its doctors' training and has for years sent them on goodwill missions abroad to provide free health care in poor countries.
In 2006, the U.S. created a special visa program specifically for Cubans on those missions, and more than 1,500 Cuban doctors, dentists and other medical professionals have used the visas to flee to the U.S., according to the State Department.
It's unclear how many doctors face the same problem as Carmona. The Educational Commission for Foreign Medical Graduates, a private nonprofit that oversees the accrediting process, said at least 20 have asked for waivers because of problems getting documents. And the numbers are likely to grow.
Emilio Gonzalez, former head of U.S. Citizenship and Immigration Services who helped create the Cuban Medical Professional Parole Program, said the problem was relatively new. He suggested allowing doctors to begin residency programs or other retraining as they await approval to take the boards.
"There is a credentialing problem," Gonzalez said. But, he added, "there are ways to be creative."
Even when paperwork is readily available, the American accreditation system for foreign doctors is difficult. They must pass three lengthy exams in English, which often cost thousands of dollars. But without academic transcripts, they cannot prove they studied medicine.
Carmona was among a half-dozen Cuban doctors interviewed by The Associated Press about their decision to defect while working abroad -- a move that risks not seeing loved ones again for many years. The doctors are allowed to stay in the U.S. regardless of whether they practice medicine. The federal government's "wet-foot, dry-foot" policy says any Cuban who makes it to American shores can remain in the country.
Some became disillusioned with Cuba's communist system and left to escape economic and political repression. Others were frustrated by poor living and working conditions in their host country.
The defectors described taking extreme steps, like Carmona's cowboy getup, to avoid raising the suspicion of Cuban and local officials. Most spoke on condition of anonymity, fearing retribution against family in Cuba or further problems in obtaining transcripts. Some have yet to apply for accreditation.
Carmona said he became disillusioned with the Cuban system in medical school when he saw doctors paid $25 a month and forced to moonlight in other jobs to buy food when government rations ran out.
His application was denied to work in Venezuela, where the Cuban government has sent more than 30,000 health professionals in exchange for subsidized oil shipments. Then in 2007, he was offered a post in Namibia on the West African coast just north of South Africa.
At the time, his girlfriend was four months' pregnant and had already requested a U.S. visa through a separate process. It seemed his only chance to leave.
Since the Cuban medical parole program began, 444 graduates of Cuban medical schools have passed their board exams and been accredited, according to the Educational Commission. However, it's unclear how many of those came to the U.S. under the special program.
Educational Commission Vice President Bill Kelly said physicians can submit affidavits from other doctors who attended medical school with them or request a waiver from the commission's executive board.
"Anybody who indicates they don't have their transcripts, we point them in the right direction," Kelly said.
Carmona said he had tried to talk to someone at the commission about an alternative and enlisted help from state politicians, all to no avail.
Following an inquiry by the AP, Kelly suggested Carmona contact him directly and then offered to allow Carmona to provide the affidavits.
Dr. Julio Cesar Alfonso, head of the South Florida group Solidarity Without Borders Inc., which helps Cuban medical professionals with the parole program, has been lobbying to change the accrediting procedure. He said he's talked with more than two dozen doctors in the same predicament as Carmona.
Getting transcripts authenticated can be tough even when Cubans come to the U.S. with their government's permission.
Dentist Yenia Lopez left Cuba with that government's permission in 2008 after getting a U.S. visa, which is done through a lottery program because so many people apply. Milwaukee-based Educational Credential Evaluators, which accredits foreign dentists, rejected her application because it could not reconcile two versions of her transcripts.
Lopez said she initially sent an unofficial version and then provided her original copy, but there were discrepancies between the two. The company said it tried five times to verify the documents with Cuba, then closed her case in 2010, effectively ending her chances of working as a dentist in the U.S.
"I feel like they are in Wisconsin, and they just don't understand how things work in Cuba, and how complicated it is even to obtain the simplest documents," said Lopez, who has offered to pay the cost of additional verification attempts and now works as a dental assistant. "This is the rest of my life they are deciding."
As for Carmona, he is now a medical assistant and is saving money with his girlfriend, who came to the U.S. with their baby. He said he hoped his case would help other doctors like himself.
"I just want to do what I love," he said, "to be a doctor."
By the AP's Laura Wides-Munoz