In our Winter 2013/2014 issue, Fernanda Canofre examines Brazil's struggle to attract and maintain medical professionals in the country. World Policy Journal takes a closer look at the staggeringly low number of doctors operating in South America today. In the map below, we look at each South American country and list the number of doctors available per 1000 people.
By Fernanda Canofre
BRASILIA—Juan Merquiades Duverge Delgado was born and raised in Guantanamo, Cuba. In a region where most of the economy is based on cotton and sugar crops, his father supported the family with a blue-collar job. Juan’s mother stayed at home. As is the story across much of the three Americas, Juan’s Cuba was built through the miscegenation of natives, colonizers, immigrants, and slaves. His mother’s ancestors came from Puerto Rico; his father’s came from Cuba. Juan is black. A graduate of Cuba’s Santiago Institute of Medical Sciences, Juan is a physician who became deeply involved in humanitarian health missions for the next 12 years of his life. As far as he can remember, there were no doctors in his family. So, his decision to become a doctor came as a natural calling. “I’ve seen it as a way of helping people,” he asserts. That was also the reason that led him to leave his wife and daughter at home in Guantanamo last August to go and live in Brazil.
Juan was one of the first 400 foreign doctors to arrive for the new federal program Mais Médicos (More Physicians)—an initiative of Brazilian President Dilma Rousseff’s government aimed at taking doctors to areas where there is no medical assistance—from peripheral neighborhoods of big regional capitals to small distant towns. In its first stage, the program was opened exclusively to Brazilian doctors, but candidates who arrived barely filled 15 percent of 15,000 vacancies. So in its second phase, the government opened the program to foreigners willing to fill the remaining vacancies, underwriting the cost of supporting doctors interested in working in areas where there are no physicians. Since it focuses on helping communities in need, three-quarters of the jobs are located in the northern and northeastern regions of the country. The doctor signs a three-year contract, promising to stay in the city or town designated by the ministry, receiving a 10,000 BRL ($5,000) monthly payment and dedicating his activities to basic family medicine in the community.
But the Cubans are a case apart. Both governments—Brazil and Cuba—have signed a bilateral agreement through the Pan American Health Organization. Brazil pays the doctor’s wage to the organization. The doctors receive a portion of this payment as a stipend to cover their living expenses in Brazil, and the rest is paid to the Cuban government. While some opponents see this as a form of indentured servitude, Juan believes it’s a good deal, “The government is taking good care of my family.” On August 26, Juan began his three- year stay, landing in Fortaleza, the northeastern state capital of Ceará. That same night, as his group was welcomed by the Brazilian government at a private event, Juan became the face of the federal program and the center of some of the most passionate debate surrounding medicine, access to higher education, and racism that this country has seen in a long time.
WHITE JACKETS, GRAY MATTER
Before the first Cuban doctors arrived in Brazil, several medical bodies in the country were already protesting the newly launched program. Most of the debate was centered around the Conselho Federal de Medicina (Federal Council of Medicine), a private organization that represents physicians and creates ethical standards for the profession. But its public pronouncements have represented the majority of Brazilian physicians’ thinking. In May, as soon as the creation of the program was announced by the Health Ministry, the Counsel’s president, Roberto D’Ávila, wrote an article charging that “the ‘import’ of foreign and Brazilian physicians, who had obtained a certificate abroad, hides the real reasons behind the lack of assistance in rural towns and at the peripheral areas around big cities… as if the final solution to all the Public Health System issues were at stake.” Later, in another public note, the Counsel “condemned” an “irresponsible decision from the Health Ministry,” accusing the government of “risking the lives of Brazilians, especially inhabitants of poor and distant zones,” since the program did not demand from its foreign professionals proficiency in Portuguese or a Brazilian medical certificate. To the Federal Council of Medicine, the program itself represents an “irresponsible” political maneuver focusing only on next year’s election.
Most Brazilian doctors opposed to the program protest the fact that certificate revalidation for doctors working on Mais Médicos is not mandated, though most of the Cubans have more than ten years experience. Brazilian physicians further claim the main cause for inadequate physician coverage is inadequate medical infrastructure. Though Brazil’s economy has demonstrated some remarkable growth over the last decade, there has been little progress in health care. In 2000, 2.89 percent of Brazil’s GDP was directed toward public health investments, yet by 2011 that figure had grown to just 3.9 percent. Today, according to the World Health Organization (WHO), Brazil’s total expenditure on health care, including public and private sectors, amounts to 8.8 percent of GDP, barely half of that of the United States (17.6 percent), but close to countries like Spain (9.6 percent) and the United Kingdom (9.8 percent). However, Brazil is one of the rare countries where private investment in the health system is higher than public expenditures. While 90 percent of Cuba’s health system is funded by the state, in Brazil, only 44 percent of the health system budget comes from public funds. Inevitably, Brazil’s middle and upper classes receive top-notch health care, while the poor languish. As pointed out by the WHO, “with very low levels of funding, countries cannot ensure universal access to even a very limited set of health services.” Sérgio Piola, a researcher at Brazil’s Institute for Applied Economic Research explains, “it is absolutely impossible to assure good quality full time services with the current level of public expenditure on health. There is no magic. Even with possible efficiency gains, since there are many examples of poor management and wasted resources, in order to improve the public health system, the investment of more public resources is necessary.”
The lack of physicians is still the main challenge facing Brazil, which averages 1.8 doctors for every 1,000 inhabitants, far below neighboring Argentina (3.2) and Uruguay (3.7). Even though the WHO does not have a recommendation for the minimum number of doctors that should be present in any one country, Brazil’s rates are particularly low. In at least 22 of the 27 Brazilian states, this rate is below the national average. The state of Maranhão, for example, has 0.5 physicians per 1,000 inhabitants. But the problem lies beyond the numbers. The federal government and medical groups recognize that the core of the question is actually how these physicians are distributed throughout the country.
The nation’s overseer of public health policy at Anvisa, the national agency for sanitary vigilance, Neílton Araújo de Oliveira, began his career as a doctor, later serving as city health secretary in Palmas, capital of the state of Tocantins, and was a creator of the Medical School of the Federal University of Tocantins. In his Ph.D. paper at the prestigious Oswaldo Cruz Foundation, Oliveira observes that only 5 percent of recently graduated medical students are willing to work in small, remote towns. On the other hand, 60 percent want to become specialists. “This is mostly due to the university curriculum itself, which does not prepare physicians to act without a huge technological support,” Oliveira warns. Meaning, preventive medicine or, as it is called in Cuba, “basic attention medicine,” has not been a priority during the education of most Brazilian physicians. Making preventive medicine a priority once again could be one step toward redressing an urgent imbalance.
According to the WHO, the same type of medical culture, which helped Cuba establish one of the best public health systems worldwide, could work as a solution to some of Brazil’s biggest issues. In sharp contrast to the views of a large majority of his colleagues, David Oliveira de Souza, former president of the Brazilian branch of Doctors Without Borders, used one of the nation’s leading newspapers, Folha de São Paulo, to publish an open letter welcoming the Cuban doctors. Souza identified diseases of the circulatory system as among the main causes of death in Brazil, pointed out that diabetes and hypertension are often diagnosed too late, discussed how pneumonia affects children living along rivers, and highlighted that congenital syphilis causes severe injuries in babies because their mothers didn’t have access to doctors in time. All, he concluded, are killers that could easily be neutralized with early diagnosis and preventive medical care.
The need to change the medical culture isn’t news in Brazil. In 1998, more than 10 years before the controversial Mais Médicos program was launched, the state of Tocantins had its own experience with Cuban doctors. Searching for a solution to the low number of doctors, the state government signed its own deal with Cuba, importing doctors with no local certification to work in poor and distant areas. The deal was part of Programa de Saúde da Família (Family Health Program, created by José Serra, health minister during Fernando Henrique Cardoso’s rule as Brazil’s president. Later, Serra served as the major opposition party’s candidate against the current president, Dilma Rousseff.
Neílton Araújo de Oliveira believes that in order to change peoples’ habits and attitudes toward health issues, physicians must be present in the community. Tocantins’ experience went well until 2003, when pressure by medical unions—that used to call the foreign doctors curandeiros (a derogatory term for “faith healers”)—gained strength and, then with a change of government, prosecutors determined to bring hte program to an end. Following the orders of an outraged Fidel Castro, some of the Cubans returned immediately to their homeland, while others who had already started their own families arranged to win validation of their medical certificates and remained in Brazil. Without the program, however, most of them moved to the private sector. The villages, which had benefited from their involvement, quickly returned to their previous state of peril.
As was the case in Tocantins more than a decade ago, many small-town mayors in Brazil still struggle to attract doctors to work in their villages. Hoping to find skilled candidates, they have entered a wild competition, offering high salaries and perks. In some cases, the city’s doctor paycheck surpasses even President Rousseff’s monthly income of 19,000 BRL ($9,000). To afford such salaries, many of these towns are compromising their municipal health budget, leaving insufficient resources to invest in infrastructure. That is the case of one of the nation’s poorest cities—Jordão, in the state of Acre, of Brazil’s far north.
Acre doesn’t share the same timetable as other Brazilian states. A late purchase added to the country’s territory in the early 20th century, Acre’s territory is dominated by the Amazon rainforest. Jordão, 250 miles from the state capital Rio Branco, is not easily accessible. As is the case of most such rural villages, there are no roads to reach some of the poorest towns—the only alternatives being private airplanes or boats. Some 70 percent of Jordão’s 6,000 inhabitants are living below the poverty line, while more than half the houses do not have electricity. Epidemic diseases from the Amazon, such as viral diarrhea, are common amongst people living by the river.
Antônio Cledinei da Silva, Jordão’s health secretary, recognizes that doctors do not want to work in such an environment. Of three medical openings, two are filled, but he doesn’t know how long that will last. Doctors rarely finish even a year on the job. The last one stayed for six months, until he received the offer of a better salary elsewhere. Silva says his latest attempt to find doctors who would be heading a team of local assistants was to offer a salary of 8,000 BRL ($4,000) per month—equivalent to the town’s average annual per capita income. With the Mais Médicos program, Silva says he saw an opportunity to relieve the city’s health budget, since the federal government pays the doctor’s salary of 10,000 BRL ($5,000), even more than he could offer. So he tried to apply. Unfortunately, with the poor state of Internet connectivity in the area, Jordão missed the first deadline. “But we will wait for the next time and we will keep trying. It is the only way,” he says.
PRIVATE WHITE DOCTOR'S CLUB
Back to the August night, in Fortaleza, when the first Cuban doctors landed in Brazil, while the newly arrived were being welcomed by colleagues and learning more about the mission they were about to begin, Brazilian doctors and medical students were organizing a public protest. “Inside the building, we didn’t know what was happening outside,” Juan remembers. When they headed to the buses that would take them to the military dorms where they were staying during a three-week indoctrination, the Cuban doctors were taken by surprise. They were surrounded by a group of Brazilian doctors, most of them white and wearing their white jackets, booing and yelling at the foreigners. “Slaves,” the protestors screamed. To reach the buses, the Cubans had to pass through a tight corridor between the protesters. Although Juan says he does not care about racial prejudice, he confesses the action was more than a bit shocking. “We don’t have things like this there [Cuba]. We, Cubans, haven’t been slaves since 1868, when Carlos Manuel de Céspedes signed the freedom of his slaves and invited them to fight for independence,” he says proudly, asserting that any association with slavery in his country is simply unacceptable.
The next day, the image of Juan, the black Cuban physician, surrounded by the yelling white Brazilian doctors was in every Brazilian newspaper. He became the face of the federal program. Health Minister Alexandre Padilha condemned the actions, calling them “racist” and “xenophobic,” and pleaded with the foreigners not to be intimidated by the protests. Dr. José Maria Pontes, president of Brazil’s Doctor’s Union, said the protesters were simply voicing what the Cubans represented, namely “the practice of rules common to dictatorial and authoritarian regimes,” since the doctors had been dispatched to Brazil without pay. The protests, he explained, were not directed at the Cubans themselves.
Nevertheless, the image of Juan Delgado being personally attacked by the protesters added a bitter note to the discussion. It has served to evoke a debate—not only about the already controversial program—but also regarding the true color of medicine in Brazil. It was the beginning of a debate the country has never held before. According to the 2010 census, even though 50.7 percent of the Brazilian population is self-declared brown or black, barely 13.4 percent of the country’s physicians are brown-skinned, and only 1.5 percent is black. A recent study held by the National Institute for Research in Education suggested that among the 108,033 students registered at medical schools in 2011, only 11.6 percent were black. When looking at students who complete their studies, the rate drops to 2.7 percent. This can be easily explained when examining how access to higher education, especially medical school, works in Brazil.
From the moment students enter Brazilian universities, they embark on career-oriented paths. Unlike other western nations, where students are accepted into college by writing essays, citing extra-curricular activities, and presenting records of high school grades, in Brazil, candidates must sit for a single test, similar to the SATs. Only those with the highest scores may enroll. The country has also adopted a quota system, with a small percentage of vacancies reserved for black and indigenous students whose test scores may be somewhat inferior. At the public universities, which grant free tuition to all students, the number of candidates for each vacancy is generally higher than the ones at the private institutions—especially for those competing for medical school, a career recently declared the most “advantageous” in Brazil. Public universities are usually known for the best professors and career opportunities, and their certificates carry more weight in the job market.
The competition for a place at a public university has created the phenomenon of preparatory courses. It is not unusual for students leaving high school, especially those who fail their first round of tests, to spend a year or two in these courses, in the hopes of eventually passing the standardized exams. Although these courses are not a novelty, the emergence of courses specialized in helping students to obtain a place in a medical school is relatively new. And though prices can reach the level of college tuition for each semester, their classes are always full. Not surprisingly, one’s chances of attending university are dependent on money matters. Today, 88 percent of students enrolled in universities come from private tutorial schools.
Roberta Lessa chose to pursue medicine professionally. Daughter of a physician and a nurse, she grew up watching her parents working in the health sector. After high school, Roberta spent two years in preparatory courses studying for a vacancy at the Federal University of Ceará’s medical school. After failing her third test, Roberta gave up on public college and attended Fortaleza University, a private institution. As she notes, since the medical school curriculum does not provide for paid internships following graduation, most students must depend exclusively on their families’ money to continue their studies. After six years in college, in spite of her passion for the career she has chosen, Roberta is very realistic about her prospects. “Medicine as I’ve imagined is very different from reality,” she says. “You have to abdicate a lot of things in the name of medicine.” She recognizes it is easy for doctors to find a job after graduation, “as long as you don’t mind where you will work,” but since she is considering a specialization in neurology, Roberta has little desire to work in a small town lacking medical infrastructure. “I don’t want to be one more physician who cannot solve her patients’ problems because of the [medical] working conditions,” she says.
Living in the same city as doctors responsible for the protest against the Cubans, Roberta says she disapproves of their attitude. Even though the population of the city of Ceará is two-thirds black, in Roberta’s class there is not a single black student. And she does not recall meeting any during her six years studying there. It is no wonder that each year, even with the terrible shortage of physicians in Brazil, it is increasingly common to see Brazilians emigrating to countries like Argentina, Paraguay, and Cuba to pursue their medical studies. While in Brazil the monthly cost of a university averages 5,000 BRL ($2,500), Argentinian institutions charge barely 1,600 BRL ($800), while Paraguay is a bargain at 350 BRL ($160). Neither country demands an entrance exam. And then there’s Cuba.
OFF TO CUBA
Like many Brazilians, Marcos Tiarajú went to Cuba to become a doctor. He was the first baby born at the first camp for landless workers in Brazil. After losing his mother, Marcos’ family left the movement. They came back only a few years later, when Marcos’ father was settled at a camp in nearby Porto Alegre, the capital of Rio Grande do Sul. With the support of the movement, Marcos was able to travel to Cuba to continue his studies, though he had never before dreamed about becoming a physician. “It is outside the reality of a peasant’s son, a poor person, to dream about a medical career in our country,” he says. In 2006, Marcos left for more than six years of classes at the Latin American School of Medicine in Havana, an institution created to receive poor students from other Latin countries, pursuing medical careers and willing to work in remote areas.
In 2012, when he returned to Brazil, Marcos decided to stand for the revalidation exam for a medical foreign certificate, which was mandatory if he wanted to practice medicine in Brazil, and waived only for participants in the Mais Médicos program. Named Revalida, the test is known for its high failure rates. When it was last administered in 2013, 92 percent of 884 doctors who tried, failed. But Marcos passed easily. Now, while he works on creating a medical project for the landless movement settlements, he serves at a City Health Center in Nova Santa Rita, a town with 22,000 inhabitants in Rio Grande do Sul. While the town has doctors, Marcos explains that few remain long enough to address the community’s problems and create a preventive health culture among the people. Now, he and a colleague, also a Cuban graduate, are the first working a full 40 hour week at the center.
In a nation where most blacks are poor and whites comprise the majority of middle and upper classes, medical careers have become indicative of cultural racism. Humber to Adami, an attorney specializing in racial issues, believes the quota system may slowly be reshaping this landscape. More blacks are accessing higher education in Brazil, but years of exclusion still weigh on the daily life of people dependent on the public health system. “According to some black women’s organizations, there are cases of doctors refusing to touch black pregnant women, or they do it much less frequently then they do for white women,” Adami says, describing accounts of physician’s prejudice he’s heard from black patients. But for Adami, the same organizations that denounce these practices are still failing to take action—refusing to pursue remedies in the courts, or to seek reparations or individual accountability.
DOWN TO WORK
On October 2, Juan finally reached the town where he would spend his next three years practicing medicine. After almost a month attending the mandatory program course, where foreign doctors have Portuguese language and medical classes, he left Ceará and headed to Maranhão. Juan was designated as the physician at the Indigenous Health Polo Base of Zé Doca, located 200 miles from São Luís, the capital of Maranhão. There, he will be responsible for the care of indigenous people from three different ethnic groups—Ka’apor, Awá-Guajá, and Tenetehara-Guajajara—who live on regional reserves. And, even with all his optimistic willingness to work, his workplace itself may be a challenge.
As is the case in several places receiving the Mais Médicos doctors, the health station of Zé Doca faces severe infrastructure problems. In October 2012, the Public Prosecutor’s office brought a civil action against the state for failure to comply with its citizens’ constitutional rights—denouncing the critical conditions of the medical infrastructure in place. A year later, little seems to have changed. The day Juan arrived at Zé Doca, Carta Capital Magazine reported the waiting room was filled with indigenous people protesting the lack of service, shortages of food for the sick, expired medication, and lack of instruments and medical supplies. They were also asking for the replacement of the current manager, nurses, and dentists. With the poor sanitary conditions in the town, cockroaches and vultures were multiplying. But Juan, who arrived at his new town optimistic, wearing a T-shirt that said, “We are slaves of health,” appears to be aware of the size of the challenges ahead. While he awaits the approval of his temporary registration to start his job, he searches for a house to rent in his new town.
One year ahead of the next presidential election, when people also vote for state’s congressmen, governors, and senators, there is more than just good will at stake with the creation of Mais Médicos. The debate is also about politics. At the end of September, Health Minister Alexandre Padilha, with former Brazilian President Luiz Inácio “Lula” da Silva by his side, announced he would run for governor of São Paulo. The last two candidates of the PSDB (Social Democrat Party), the main opposition party, to run for president—José Serra and Geraldo Alckmin—were both physicians and governors of São Paulo. Serra was also the health minister when Tocantins signed its pioneer agreement with Cuba to bring in foreign doctors in 1998.
While the Federal Council of Medicine sees the program as an “opportunistic measure” that “takes advantage of the public clamor coming from the streets to create a simply populist legislation,” the government’s political opponents have also taken up the cry. Senator Aécio Neves, a well- known economist, identified as the probable challenger in next year’s election to President Rousseff, condemned the program’s back door to creating a new “medical career” plan.
For her part, President Dilma Rousseff has announced that 25 percent of oil royalties from the nation’s recently discovered pre-salt layer will be invested in the health sector. The other 75 percent will be directed toward education. The estimate, according to the Brazilian National Oil Agency (ANP), is that pre-salt oil royalties will amount to 300 billion BRL ($137.5 billion) in 30 years. Clearly, the president appeared to be seizing on a substantial political opportunity, since a recent opinion poll showed 70 percent of Brazilians are in favor of the Mais Médicos program.
The program is also promising to transform the entire nature of medical instruction in Brazil’s universities. The government plans to create 11,500 new vacancies for medical schools throughout the country by 2017. Last August, a new model medical school was created at Passo Fundo, a city in Rio Grande do Sul. Students are accepted based on a racial quota system and, during their graduate studies, are required to attend to people living in indigenous, rural, and otherwise neglected communities in the region. As Brazilian journalist José Hamilton Ribeiro observed in 1968, “In a place where people are well-taken care of, one doesn’t die by chance, from an avoidable or curable disease.” Given the introduction of new medical schools, such as Passo Fundo, Brazil is poised to embed Ribeiro’s idealistic words in the nation’s infrastructure.
Fernanda Canofre, a Brazilian journalist, writes frequently about social issues for Global Voices Online.
[Photo courtesy of Karina Zambrana]