Terezinha de Jesus thought her mother, Catarina, was finally getting the help her Alzheimer's required. In 2016, after years of only seeing doctors in cases of absolute emergency, 78-year-old Catarina was finally receiving regular care and attention through Mais Medicos, an enormously popular program that placed thousands of doctors in some of the country’s most violent and neglected communities.
For the de Jesus family, Mais Medicos meant that 18 doctors (16 of them Cuban) arrived to their town of Embu Guaçu, just southwest of São Paulo, and started providing the sort of healthcare that had long been out of reach to them.
Then Jair Bolsonaro won Brazil’s presidency.
On November 14, facing mounting threats from the newly elected president, Cuba announced it would repatriate over 8,300 doctors — nearly half the program’s professionals — from Brazil. The Cuban government said Bolsonaro’s “unacceptable conditions” made “it impossible to maintain the presence of Cuban professionals in the program.” Bolsonaro celebrated the announcement as a victory in his emerging war on leftist countries Venezuela, Nicaragua, and Cuba, but the hasty withdrawal has left a meteor-sized hole in healthcare for some of Brazil’s most vulnerable communities.
Now, the new president must find coverage for the estimated 24 million Brazilians who'd been receiving care from Cuban doctors. He’s vowed these vacancies will be easily filled by Brazilian doctors, but the deadline to fill positions — originally set for Dec. 14, 2018 — has already been extended three times. Doctors now have until March 27 to show up to their posts, over three months past the government’s original goal. Bolsonaro's office did not respond to multiple requests for comment.
That gap in coverage could have a dire effect on the neediest communities, said Luiz Augusto Facchini, research coordinator of the Brazilian Association of Collective Health (ABRASCO).
“Imagine you live in a remote place, with precarious transportation and conditions of living and assistance,” Facchini told VICE News. “Losing [those doctors] for an extended timeframe will cause a serious problem.”
Mrs. de Jesus doesn’t have to imagine; the loss is already being felt in her mother’s home. “We will be put through a very difficult situation without the Cuban doctors here,” she said.
Where is the Doctor?
Mais Medicos was created in 2013, as an emergency response to a national campaign by mayors called "Cadê o Medico" (Where is the Doctor?), which highlighted the difficulty of hiring and keeping medical professionals in marginalized communities throughout Brazil.
Then-president Dilma Rousseff had great ambitions for the program, including reforming and expanding Basic Healthcare centers, supporting doctors in their pursuit of specializations, and most importantly, placing professionals in 4,058 municipalities — some 700 of which had no medical presence at all.
But the program was hobbled from the start: Despite overwhelming enthusiasm among Brazil’s medical professionals to fill 18,240 vacancies, only 900 actually showed up to work. That forced the Ministry of Health to open the remaining 17,000-plus slots to foreign doctors. Cuba quickly pounced on the opportunity by signing a contract that would fill Brazil’s vacant medical positions with the communist country’s greatest export: doctors.
“Cuban doctors changed our reality here.”
"Cubans were never our first choice of doctors, and our plan from the beginning was to eventually replace them [with Brazilians],” said Mateus Falcão, who helped implement the program as a special adviser to the director of Mais Medicos from 2013 to 2016.
Finding Brazilian doctors willing to work in rural areas remained a constant obstacle, and when all was said and done, Cubans ended up representing nearly half of the Mais Medicos workforce.
Those receiving healthcare for the first time didn’t care about the confusion, however, and the program soon became enormously popular.
“Cuban doctors changed our reality here," said Dr. Maria Dalva Amim dos Santos, Embu Guaçu's health secretary. "After their arrival, we were able to provide our entire population with assistance in our Family Health units!”
Reviving the war on communism
Though the arrival of foreign doctors was welcomed by those most in need, it immediately stirred controversy in the country’s capital. The Brazilian Medical Association (AMB), the nation’s association of physicians, alleged Cubans were performing "illegal practice of medicine on Brazilian grounds." Others took issue with the fact that the program didn’t require participants take the Revalida, an exam for doctors trained outside the country, and conservatives balked at the idea of Dilma’s government aiding Cuba’s communist regime through the program.
Bolsonaro seized on the paranoia surrounding the program to grow his national stature. In 2013, then a federal deputy from Rio de Janeiro, Bolsonaro called the doctors “agents” of the Cuban regime and “a danger to [Brazil’s] democracy.” He returned to this attack repeatedly during his 2018 presidential campaign, promising voters, “With the stroke of a pen, I will send the Cubans back.”
“I think Bolsonaro made his decision for largely ideological reasons, but it doesn't mean he was wrong.”
Bolsonaro continued ratcheting up the heat after his victory, proposing stiff reforms to the program. First, he said, Cubans would need to pass an equivalence test to prove they were qualified to practice in Brazil. Second, the Cuban government would no longer be allowed to keep 75 percent of the doctors’ wages. Finally, Cuba would have to allow the doctors’ family members to move to Brazil — a demand that contradicted previous provisions he’d authored, barring these family members from legally working in the country.
Though experts agree that Mais Medicos had many pressing flaws, including failing to outgrow its initial emergency aims and building a lasting healthcare infrastructure for rural communities, Bolsonaro’s preoccupation with Cuba’s role in it suggests the decision was based on ideology rather than true reform.
“I think Bolsonaro made his decision for largely ideological reasons, but it doesn't mean he was wrong,” said Brian Winter, editor-in-chief of Americas Quarterly. "To me, the question is an ethical one: Should Brazil try to solve its own problems by relying on imported labor it contracted from a dictatorship?”
"It's a complicated dilemma, with human consequences,” Winter added.
A week after Cuba announced the withdrawal of its doctors, the Ministry of Health released an emergency public call for Brazilians with national medical degrees to fill the new vacancies. At first, the call drew a promising response: 36,490 applicants registered for 8,517 positions. Bolsonaro, too, appeared delighted, boasting on Twitter that nearly 100 percent of the open slots had already been filled. He returned to this subject again during his inauguration on January 1, exclaiming that "the [Brazilian] people have started to liberate themselves from socialism."
Despite the initial flurry of enthusiasm, the Ministry of Health was soon experiencing a case of deja vu: In the face of diminishing interest, a second public call for doctors was released, this time opening slots to foreigners. According to the ministry’s latest figures, released January 15, at least 1,533 positions remain unaccounted for.
The situation could get worse. Over 200 doctors have already withdrawn from their new posts, citing difficult access to health centers and poor working environments. Experts expect this number to grow, as more doctors arrive in rural communities with less-than-ideal working conditions.
“The big dilemmas are exactly like what we had before.”
"We need to watch closely for developments," said Walter Cintra Ferreira Junior, a coordinator of the Hospital Administration and Health Systems program at FGV University in Sao Paulo. "People can fill spots, but the real question is whether they will stay in their posts — which is and has been our biggest issue."
For Brazil’s medical professionals who oversaw the last iteration of Mais Medicos, the current crisis feels a lot like the old one. On January 7, Mayra Pinheiro, the new administration’s coordinator of Mais Medicos, urged Cuban doctors still in the country to reapply for the program.
“The big dilemmas are exactly like what we had before,” said the professor Facchini, who fears that each day the government fails to restore the program, the more working-class Brazilians will suffer. “Mais Medicos has not ended, but at least half the doctors, who were precisely in places of greater need, have left — so for people in those areas, the program is over."
Cover: Brazil's President Jair Bolsonaro gives a thumbs-up to the press as they wait for Argentina's President Mauricio Macri at Planalto palace, in Brasilia, Brazil, on January, 16, 2019. (Agencia Estado via AP Images)