Tom Gatehouse blogs from Belo Horizonte.

According to the World Bank, Brazil has just 1.8 doctors for every 1000 people. The figure for neighbouring Argentina is 3.2, whereas in countries such as Spain, Switzerland and Norway the figure reaches 4.0 and above. In Brazil’s larger metropolitan areas the figure is higher than the national average, but in many rural areas the figure is much lower, effectively falling to zero in some 700 municipalities. Matters are complicated further by the country’s profound social inequality, and access to medical care is highly conditional upon one’s ability to pay. Unlike in Europe, public services in Brazil were never seriously intended to be universal; rather, they serve as a kind of deposit for those unable to pay their way through the private sector. Even in the richer cities of the south and southeast, the public health system is severely underfunded, understaffed and overcrowded, unable to compete with a private sector of immense wealth and power.

While not all of the Cuban doctors are black – the sight of white doctors yelling the word ‘slave’ in the face of a black man has some deeply unpleasant echoes in a country in which slavery was practiced for 80% of national history. It’s not for nothing that the healthcare issue was one of the principal complaints of the protestors who took to the streets in June. And yet, when the government unveiled a scheme to import doctors from abroad to work in some of Brazil’s poorest regions, the response by many, including most of the press, and, significantly, local medical associations, was open hostility. The proposal was made as part of Mais Medicos (More Doctors), a programme which also contained plans to build new hospitals, to invest in drugs and equipment, and to create 4000 vacancies for new junior doctors. However, one could be forgiven for thinking that the government’s only proposal was to bring doctors from abroad, such is the level of attention it has received, most of which has been negative. So why, in a country seriously lacking in health professionals, has this proposal aroused such fierce opposition?

Many seemed almost offended by the idea that foreigners might come to work in Brazilian hospitals. But importing health professionals has long been standard practice in many developed nations. The NHS is heavily dependent on foreign workers, not just doctors but also nurses, porters, cleaners and pharmacists. Foreign health professionals are also common in countries such as France, Norway, Canada, and increasingly in the United States. If highly developed nations such as these cannot educate enough professionals to staff their hospitals, why should Brazil be an exception to the rule? Moreover, it is not clear why importing doctors should be such a bone of contention, any more than importing engineers, technicians, scientists and so on. Brazil has been taking steps in recent years to attract these kinds of professionals, providing jobs and salaries and trying to do away with bureaucracy and red tape. Nobody complains about the arrival of these individuals, so why the different attitude when it comes to doctors?

Particular hostility has been reserved for the Cubans, who were heckled on their arrival in the country by their Brazilian counterparts. While the press initially – in rhetoric taken straight from the Cold War – labelled the doctors as communist spies, they have recently changed tack. Under the deal struck between Brazil and Cuba, the Cuban government is due to receive a proportion of the doctors’ salaries. The accusation is thus that the Cubans are slave workers, and escravo (slave), was the chant directed at them when they arrived in Fortaleza.[1] The present narrative is that these Cuban doctors are being sent against their will to remote areas of the country, where the facilities are so primitive they will be able to do little for their patients – and to top it all, Fidel takes a cut of their salary!

However, Cuban doctors are accustomed to working in contexts and situations often a good deal more precarious than those they will encounter in rural Brazil. Cuba currently provides more medical assistance to the developing world than all of the G8 countries combined, and has a long history of doing so. The first Cuban international health brigade was sent to Chile in 1960 following a major earthquake, and since then they have worked extensively in war zones and in the aftermath of disasters, both natural and man-made. Cuban doctors treated victims of the Chernobyl disaster; they worked in Indonesia and Sri Lanka in the aftermath of the tsunami in 2004; they were sent to Pakistan following the Kashmir earthquake in 2005; and they were instrumental in controlling the cholera outbreak following the earthquake in Haiti in 2010.

The critics not only overlook the positive impact that Cuban medical teams have had all over the developing world, but also the particular nature of Cuban medicine and its applicability to the Brazilian context. Cuba does not have the same access to drugs and medical technology as the developed nations, and yet, Cuban rates for child mortality and life expectancy are superior to those for the United States, according to the World Bank and the World Health Organization. Cuban medicine manages to do the same or better with a lot less, taking a prevention-based approach which aims to keep people healthy rather than treating them once they are sick, emphasizing, for example, correct nutrition and hygiene. This has had enormous success in developing countries in which many people continue to suffer from conditions which either do not exist in the developed world, or which have been successfully contained for decades, such as infant mortality, malnutrition, malaria and so on. There is no reason why this approach would not achieve results in poor areas of rural Brazil.

As for the issue of their pay, they have come to Brazil as part of a deal brokered by the Pan American Health Organization, under which the Cuban government will receive a proportion of their salaries. The exact amounts remain unknown. Slavery it is not, though there is a legitimate concern over parity of wages between the Cubans and their colleagues from other countries, and the government should be clearer on this point. Still, we should not view the issue in purely economic terms. Cuban doctors working both within their country and abroad are well aware they could be paid many times more for their work in other countries – and they do not all defect. The reason being that people are not motivated exclusively by economics, especially when it comes to questions of health and wellbeing. Sometimes the strongest motives are not monetary in nature at all.

One final objection raised by many is that the foreign doctors amount to no more than a sticking plaster: they are a short-term solution aimed at securing Dilma’s re-election. These critics argue that the money would be better spent on new medicines and equipment, on renovating hospitals and educating more Brazilian doctors. However, Dilma promised all these things as well. True, Brazilians are used to politicians breaking their promises, and it is no surprise that many are sceptical. Still, it is hard to see what else she could have done. As the Spanish sociologist Manuel Castells said, Dilma’s response to the protests was that of a democrat: she listened to protestors’ demands and came up with a series of proposals aimed at addressing them. It appears that with her opponents she is damned either way. If she had ignored the protests, she would have been portrayed as cold and out-of-touch; instead she responded, and is accused of hypocrisy and electioneering.

Although you might not think it from a casual glance at the newspapers or the television, the majority of the Brazilian population is in favour of these measures. According to a recent Datafolha survey, 54% of the population approve of the government’s plan to import foreign doctors. Those in favour are more likely to be from smaller cities in the northeast (60%), while most of those against are likely to be wealthier, better-educated, and live in larger cities where there is not such a shortage of doctors – in other words, the very same people who do not stand to benefit from the government proposals. What these statistics show is a country profoundly divided by region, class and of course, politics.

However, at the root of all this there is a humanitarian question which is serious, urgent and not at all difficult to grasp, and that is that there are an estimated 11 million Brazilians who do not have access to medical care. These people do not care where their doctor comes from. They do not care, necessarily, if their doctor does not speak fluent Portuguese, or if their credentials have been ratified by local medical associations. But they do care about their health, and the health of their families, and they recognise that having access to a doctor – even one with limited resources – is better than having no doctor at all. Those who oppose Mais Medicos – the majority of whom have healthcare coverage – would do well to stop, take a deep breath, and imagine for a moment how they might feel in that position. What would you choose?


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