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RIO DE JANEIRO—Marielis Isabel Fonseca first became familiar with Brazil through soap operas: the ravishing seaside, the rich culture, the cordial, hardworking people. Still, when she left her native Cuba in August 2016 to work as a doctor in Campinas in the state of São Paulo, she felt insecure. Fonseca was assigned to a primary health care unit in a neighborhood plagued by crime. Language was proving to be a barrier. But Fonseca was also a psychiatrist and had a way with people. She had spent five years since 2003 practicing in Venezuela, an experience she says improved her “both personally and professionally.”
Soon, her Brazilian patients, whom she treated mainly for diabetes, high blood pressure, respiratory diseases, and substance abuse, were telling Fonseca, “Doc, you take care of us and we take care of you,” as they walked her to the bus stop nearby. With some, Fonseca formed even stronger ties. She currently lives with the widow of one of her patients, who passed away in his 70s from stomach cancer. “It’s a Cuban idiosyncrasy,” Fonseca says. “If you work in the community, you become family.”
As many as 20,000 Cuban doctors have moved to Brazil to work as part of the Mais Médicos (“More Doctors”) program, an initiative launched by Brazil’s then-governing Workers’ Party in 2013 to place primary care physicians in some of the country’s most underserved and poor regions, including indigenous villages. The cooperation agreement between the Brazilian government, the Pan American Health Organization (PAHO), and the island ties in with a long-standing fixture of Cuba’s soft power. With its a high number of doctors per capita and investment in a public health care sytem, Cuba “exports” medical workers through humanitarian missions like the one in Brazil. Since the aftermath of the 1959 revolution, Cuba’s international medical outreach efforts have served as a strategy to counterbalance the isolation and embargo imposed by the United States, earning the island billions of dollars in revenue every year.
There are currently 28,159 Cuban doctors and nurses working in 59 countries. Over the years, Cuban doctors have served 60 million Brazilians across 4,000 localities and 34 indigenous villages. More than 700 of the country’s more-remote communities had a resident primary care physician for the first time as a result of the More Doctors program.
But in November 2018, Fonseca learned that she would have to stop practicing in the country that had welcomed her two years earlier. And she wasn’t alone. In the aftermath of President Jair Bolsonaro’s election, as many as 8,500 doctors suddenly became jobless when the Cuban government decided to end the 5-year-old agreement, citing as a reason the Brazilian far-right president’s “direct, contemptuous, and threatening comments.” During his terms as a congressman and throughout his campaign, Bolsonaro promised to “expel” the doctors, questioning their credentials and saying they were in Brazil to form guerrilla groups. Ecuador and Bolivia have also withdrawn from similar agreements under pressure from the U.S. government, which accuses the Cuban regime of exploiting medical workers by keeping 75 percent of their salaries.
When the cooperation came to a halt, thousands of doctors were faced with a dire choice: to remain in the country that had become their home and risk being punished as deserters by the Cuban government, or go back to the island. At the time, Cubans made up roughly half of the More Doctors program’s total workforce of 18,000 physicians. About 2,000 stayed in Brazil but lost their authorization to practice medicine. Fonseca, who held a temporary resident status, was among them. In order to make a living, she tried working at nursing homes and drugstores, but people kept asking her what a doctor was doing behind a counter. Fonseca took massage and holistic therapy lessons and eventually landed a temporary gig at a beauty clinic. She has been unemployed for five months now, relying on the support of family and friends living abroad.
After the Cuban doctors left, or were barred from practicing, the Brazilian government scrambled to replace them. Although spots quickly filled up with the Brazilian doctors who have priority to enroll in the program, many left their posts soon after or failed to present. “Not every doctor is willing to go anywhere in the country,” says Socorro Pena da Gama, a public management and regional development professor and lawyer supporting the cause of a group of 83 Cuban doctors in the northern Brazilian state of Pará. “But [Cubans] have an ethical commitment.”
When Yulia Molina Hernandez joined the program in March 2014, she became the first doctor at a new primary health care unit in Cabaceiras, a 5,000-person town in the state of Paraíba. “The patients were curious to meet the foreign doctor,” she says. “They wanted to hear my accent.” Hernandez tended to between 20 and 25 people a day. But in 2017, she decided not to go back to Cuba to renew her contract. Hernandez was pregnant and at risk for a preterm birth, so her doctor instructed her not to travel. She has since been barred from going back to Cuba, where she has an 11-year-old daughter, for at least eight years.
Margaret Garcia Torres, who was part of medical diplomacy missions in Pakistan during the 2005 earthquake and spent two years fighting malaria and cholera in Angola, now works as an administrative assistant at a Rio de Janeiro state hospital. “I spend the entire day in front of a computer producing documents,” Torres says. “But this is going to have to change because they’re going to need us.”
Indeed, the shortfall created by the program’s cancellation has only become more dire over the last month. Hundreds of Cuban doctors have recently joined the fight against COVID-19 in at least 14 other countries, including some of the worst-hit areas of Italy. But in Brazil, Cuban physicians, many of whom have hands-on experience in preventive medicine and a track record of being at the forefront of response efforts to major disasters and epidemics—such as the outbreaks of Ebola in western Africa and cholera in Haiti—are being pushed to the sidelines.
“The whole world is begging for more doctors and we’re here, being wasted,” Fonseca says. “We feel unappreciated.”
Since the termination of the agreement that placed Cubans in the More Doctors program, these doctors haven’t been allowed to practice in Brazil unless they validate their diplomas through an equivalence test, which hasn’t been offered since 2017. But in December 2019, some had their hopes of going back to work renewed when Bolsonaro signed a law establishing a new program to gradually replace the old one. The legislation would allow Cuban doctors who met certain legal requirements to reintegrate with the program for two years.
Then, in late March, hope turned into disappointment. The government issued a public call for Cuban doctors to join the efforts against the coronavirus, but many were surprised to learn they were being left out. Only those on a list published by the Ministry of Health were eligible to apply for reinstatement. While 1,879 names were listed, as many as 1,200 qualifying candidates have been excluded, according to lawyer Humberto Jorge Leitão de Brito, who is representing Cuban doctors in legal actions. More than 15 doctors I spoke with told me their names were not on the list, even though they fulfilled all the conditions set forth in the legislation.
“The list includes doctors who have gone back to Cuba or moved to Uruguay, Mexico, and the United States, and even some who are deceased,” says Wilder Gonzales Diaz, whose name wasn’t on the list. Since the end of his participation in the program, Diaz has been living in a small town in the northeastern state of Alagoas, where jobs are few and far between. He has turned to cleaning houses and working in the fields.
A federal judge recently sided with the Cuban doctors, but the Ministry of Health has yet to respond. Email exchanges shared with me show that the Ministry of Health told doctors that the PAHO, a subsidiary of the World Health Organization, was responsible for the list, while the organization denied having any information about it and advised the doctors to contact the ministry. When asked about the dispute for this article, a government spokesperson said it would offer an opportunity to all Cuban professionals who meet the conditions set out in the law. The PAHO didn’t respond to a request for comment.
The government estimates that 90 percent of cases of COVID-19 in Brazil can be treated in the kind of primary health care units that are at the core of the More Doctors program. In response to the increasing number of confirmed cases and deaths—23,944 and 1,361 respectively, as of Tuesday—the government has put out a call for 5,811 doctors to serve for one year in densely populated areas, where the spread of the virus has been most severe. The recruitment process, however, favors Brazilians and professionals who had their diplomas validated, to the detriment of most Cubans.
It also ignores Brazilian doctors who received their degrees from foreign institutions. Many of them were also active in the More Doctors program for years and are now facing the end of their contracts. When asked if the Ministry of Health intended to call these physicians to fight the pandemic, a spokesperson said it would consider “all the possibilities of administrative measures for future deliberation according to the need and opportunity that the situation requires.” So far, the government has focused its outreach on late-stage medical and physiotherapy and pharmacy students as well as other professional categories like veterinarians and nutritionists.
In the meantime, Cuban doctors are trying to help in whatever way they can. They are talking to patients from the drugstore counter and advising people to stay at home via social media. Fonseca says she wakes up at 6 in the morning and goes to bed at 1, answering people’s questions about the virus over the phone. And like that, they hold onto the only thing no one can take from them. “The lab coat is just an attire,” she says. “We haven’t stopped being doctors.”