By Ana Lidia García (El Toque)
HAVANA TIMES – “Doctor, today the windows are to cleaned”, “Doctor, this needs washing …” For the owners of the houses where she worked for months doing housework, Idalma was still ‘the Doctor’. She was never called by her name.
Idalma Leyva, a 54-year-old Cuban doctor and specialist in ‘Comprehensive General Medicine’, lives in Nova Odessa, São Paulo, Brazil. Many things have happened in her life, ever since last November 13th.
On that day, the Cuban government withdrew from the ‘More Doctors’ program, a collaboration agreement between the Brazilian government, the Pan American Health Organization (OPAS) and the government of Cuba, which had been signed in 2013 during the presidency of Dilma Rousseff. Once Cuba left, the program was closed on February 7, 2019.
Idalma is one of approximately 1,800 Cuban doctors who decided to not return to Cuba in November 2018 as the Ministry of Health instructed. From that moment on, she had to adapt to new living conditions in Brazil. First, her permission to practice medicine became invalid (as a result of the contract’s end with Cuba) and then the non-inclusion of Cuban doctors in the calls launched by the Brazilian government in December and February to cover the places left by the islanders.
The Havana native, from the Regla municipality, thus spent several months helping Brazilian friends in their household chores. There, they gave food and shelter to her and her teenage daughter and for such, she will be “forever grateful”. Later on, she took care of an old man with Alzheimer’s and did whatever housework the lady asked of her. Throughout this entire time, she earned a minimum wage that was enough to pay basic bills.
Today, she and her colleagues await the publication of a ‘call’ that would allow them to practice Medicine once again in Brazil.
Cuba says it has sent almost 20,000 professionals to Brazil since 2013. According to statistics from the Island government, 113 million patients benefited from the medical care of Cuban doctors. Havana decided to unilaterally break the agreement with Brazil following the criticism of the elected-President Jair Bolsonaro, and his proposal to renegotiate the agreement.
An opportunity opens up for a large number of Cuban doctors in Brazil
On August 1st, 2019, the General Secretariat for Legal Affairs of the Brazilian Presidency published a provisional measure on creating the program “Doctors for Brazil”, which would replace the “More Doctors” program.
Since that date, the association of Cuban doctors in this South American country (ASPROMED) – with the support of Brazilian lawyers, has managed to initiate dialogues with senators, congressmen and representatives of the Ministry of Health so that they consider the incorporation of Cuban doctors into this new program, which they had not been previously contemplated for.
After several sessions of exchanges and amendments to the provisional measure of August, on December 18, President Jair Bolsonaro signed Law No. 13,958, which formalizes the Doctors for Brazil program and had been approved by the National Congress. This initiative aims to increase the provision of medical services in places that are deprived and of high vulnerability in this country as well as promoting the training of doctors – specializing in family and community medicine.
The final provisions of the law specify that exchange doctors (including Cubans) will return to the program for two years if they meet the following requirements:
- That they had been in the exercise of their activities, on November 13th, 2018, within the scope of the More Doctors Project.
- That they have been disconnected from the More Doctors for Brazil project due to the rupture of the cooperation agreement between the Ministry of Public Health of Cuba and the Pan American Health Organization / World Health Organization for the supply of doctors in this Project.
- That they have remained in Brazil through the date of publication of Provisional Measure No. 890, of August 1st, 2019, as naturalized citizens, residents or applicants for political refuge.
Between 1,800 and 2,000 Cuban doctors could join this new program. Those approved will receive a training grant of 12 thousand Reais (USD 2,674.70) per month.
As part of More Doctors, the government of Cuba paid its doctors 2 976.26 Reais a month (approx. 663 USD). Those who are to be integrated into the new project, will receive 9,023.74 Reais (2,011. 31 USD) – far more than during their years spent in the More Doctors campaign.
Waiting for the miracle
“This law says that we will be able to work for two years without CRM (a code that enables you to work as a doctor in Brazil). During this time, they will allow us to do the revalidation exams, preparatory courses for this exam and a specialization that is also done here,” Dr. Vania tells us via WhatsApp.
Vania also mentions that after the approval of the law came the December holidays, which extended into January, and although they expected that the call would be published in February, they still do not know anything.
“Many media outlets have reported the news; the Secretary of Primary Health Care has hinted to the immediate reinstatement of Cuban doctors. However, the days go by and they don’t announce it,” says Vania through an audio message.
At the moment – she explains, only one document has been published through which the Secretariats of Health are asked to analyze all the vacancies, which must be covered by the new Doctors for Brazil program.
While waiting for the call with all the indications and requirements to join, this doctor keeps working at a hotel in the Puerto Seguro municipality, state of Bahia. “Work is from 6 a.m. to 2 p.m., at café da manhã, and in the evenings – whenever I can – I study for my revalidation exam”.
Passing the “Revalida” – an examination that allows the homologation in Brazil of diplomas obtained abroad – is a mandatory condition for doctors who studied abroad to practice in the country.
Foreign health professionals who participated in the state’s More Doctors program could practice medicine in primary care without Revalidation. At the end of the program last November, this condition was made invalid. The substitute program, Doctors for Brazil, will offer the same privilege for a period of two years – to all doctors who have studied abroad.
Vania tries to summarize how these 15 months have been after Cuba left the More Doctors program; months in which getting work was one of the most difficult tasks.
She said: “wherever you arrived and said – I want to clean the floor, wash dishes… they said to you, no, but we can’t pay you. They thought that by doing these jobs, we wanted to be paid as doctors. Or if they didn’t answer you with that – they said – no, we can’t hire you because you’re a doctor. For them, doctors are high class and they can’t imagine that one could be doing any other kind of work.”
In the municipality of Pernambuco state where she had been working as a doctor since her arrival in Brazil, Vania could not find a job. Therefore, together with her husband who had arrived from Cuba since before November 13, 2018, she decided to move to the state of Bahia, to a tourist area where work opportunities were greater.
Since those first months she also remembers that she and her husband began the process of requesting political refuge to obtain a legal stay in the South American country. It was the option they had given to those who were in their condition. They had already requested the Shelter Protocol, a process that can take years to be granted and can also be denied.
“When the measure came out, it stated that all Cuban doctors who had stayed on in Brazil after Cuba’s break with the program (and the relatives who were here with us), had the possibility of applying for a temporary residence in the country for two years.” She even clarified they could make a statement that they were not working – allowing them to do the procedure at no cost.
“At the end of those two years, even 90 days before, we have the right to request permanent residence in Brazil. That was a big step, nobody imagined that we were going to be able to do this procedure so quickly. That was one of the benefits we received,” says Vania.
The big dream: going back to work as a doctor
“I have a 10-year-old daughter who is staying in Cuba. Imagine how much I look forward to that law, which will allow me to work for a good salary, raise money and do all the paperwork to bring her here.”
Traveling to Rio de Janeiro, the capital, can take Dr. Herling Hernandez six hours by plane. Since arriving in Brazil, he lives in Brasileia, a municipality in the Acre state, on the border with Bolivia. It is currently impossible to move from there because of the transportation costs.
It was mostly the remoteness that was one of the main factors, which led him to stay in the same place where he had worked [during More Doctores]. In addition, he found work there as an assistant in a pharmacy. “I consider myself blessed, I have maintained a good job, my wife and I haven’t been without.”
More than a year later, Herling retains the same position.
“In the pharmacy I cannot prescribe, but if someone comes to buy a wrong medication, I can tell you the right one and even tell you how you can use it. Nor can I do a physical exam, but as there are many medications that are sold without a prescription, I do have some chance to help.”
Herling has felt the support and respect of those who were his patients before and, even, Brazilian colleagues have lent him study materials to prepare and be able to present himself to the Revalidation as soon as they allow it.
Cuban doctors and Brazilian communities
Dr. Idalma has a long list of anecdotes of solidarity and doesn’t wish to forget any.
“When two Brazilian friends, Roxana Matos and her husband, saw where my daughter and I were living, they went to look for us and lent us the basement of their house with a large room and a bathroom, in Sumaré – totally free. We have been living here for 7 months, and although I have been paying whenever I could, the help has been immense. We even had furniture and good living conditions.”
At least in her municipality, Nova Odessa, the local government and other colleagues helped her a lot after November 13th, 2018. “In my prefecture, when our contract as part of More Doctors ended, they gathered us and gave us a diploma of ‘distinguished service’, and for three months social security was helping us. I am not saying that this occurred in all the municipalities, because there are in fact diverse opinions on this subject but in my municipality, it was like that”.
Furthermore, Idalma recalls: “when it was learned that I was alone with my daughter and already without receiving a salary, they prepared [in the health post where I worked] a box that said “Doctor Idalma”, in which the nurses, the other doctors and cleaning assistants were depositing food. When it was full, they brought it to me.”
Nor does she forget the support networks among Cuban colleagues that have been created and strengthened in these months.
Raúl Manuel also accumulates several experiences on this subject, for example, he lived three months without paying rent or services. The owner wanted to help him. Then, with the help of the prefecture he found an administrative job in the area of ??health surveillance, which allows him to remain linked to medicine in some way.
From this position – however, he has had experiences in which – as a doctor he could have acted and, on the contrary, he had to remain silent. “They come from so far, they greet me, they ask me for a prescription or to diagnose them, and I have to explain to them [that I can’t]. Some live in places so far away that they have little access to information and aren’t really aware of what happened to us.”
Vania says: “Imagine how difficult it is for me. In my work they ask me to review the exams, to treat them, but with a pain in my soul – I tell them to look for an authorized doctor”.
A new beginning for some
“The Ministry of Health has been busy with floods in Minas Gerais, in São Paulo; and also, with surveillance in relation to the coronavirus,” says Dr. Raul Manuel.
In his opinion, these factors have also delayed the ‘call’ for the new program.
“When I made the decision to stay, it was clear that it would be difficult because in any foreign country it is difficult to practice as a doctor. However, here it was a different element, which is that we were already practicing medicine in this country”.
“I thought that they would allow us to continue with the contract for the period that we lacked and that it would give us time to raise the money for the Revalidation. Now it is that the opportunity reappears and it has been traumatic because one always dreams of exercising what he or she studied and from one moment to another we saw ourselves in a limbo, in nothingness…”
Raúl dreams of being able to homologate his title in Brazil and of being able to have his daughter and mother close by, who remain in Cuba. Integrating the new state initiative seems to be the way to achieve it.
Although he enters the group of around 1800 Cuban doctors who will benefit from this opportunity, it is estimated that approximately 600 island professionals are being left out.
They are those who had left the More Doctors program before it ended or were separated for various reasons, including refusing to have their family members return to Cuba after three months of visiting Brazil, the maximum period authorized by the Cuban authorities.
“The Brazilian government allowed our family members to be with us for 11 months, but the coordination here told us that it could only be three”, explains Dr. Raul.
“I brought my ex-wife,” says the Holguin doctor. Immediately on her arrival, the coordinator asked me for her details, the date of her return and a photo of the ticket. If another day passed after three months, you were withdrawn from the program. She returned to Cuba right after three months. I have a colleague who kept his wife and young son hidden for six or seven months. He had to hide them from his colleagues because if they saw them, they were supposed to tell the Coordinators.”
Lisset* was one of the doctors who could not renew her contract due to discrepancies with the coordination of the program. “I was seven months pregnant and a threat of pre-term delivery and so they wanted me to return to Cuba. I refused to return and for that reason they didn’t renew my contract, they separated me from the program. I had the right to renew the contract because I was married here. I saw it as inhuman, but it wasn’t going to put my baby’s life at risk. I had all the requirements to renew, but I couldn’t do it.”
For not being part of the More Doctors when Cuba abandoned it, Lisset will not be able to join the Doctors for Brazil program. She is happy for the colleagues who do meet the requirements, but for her there are still no possibilities to practice the profession.
“The Association of Cuban doctors in Brazil lawyer says he will fight for us, but I honestly have low expectations,” says Lisset.
For Idalma, Vania, Raúl and Herling the road seems to be paved, others like Lisset are still waiting. Everyone is clear that they will continue in Brazil and maintain the desire to exercise their profession there.
Information on the cities and municipalities that will need doctors is not available yet, in any case, those with the highest levels of vulnerability will be prioritized. The definition of these details and the organization of the agency in charge hold up the urgency of these professionals to start the work.
Luiz Henrique Mandetta, Minister of Health of Brazil, had predicted that the first call for proposals for the program would be published in February and that professionals would begin their work in April.
*pseudonym used at the request of the interviewee.