South
Africa's Latest Cuban Import: Doctors
Cubans help stem brain drain but face
complaints of preferential treatment.
By Chris Gaither
JOHANNESBURG, South Africa — For the last five years, more than 400 Cuban doctors have brought medical care to South Africa's most impoverished rural areas, They answered an international cry for help in plugging a brain drain that is depleting the nation's public health ranks.
To supporters, the Cuban medical presence here signifies the island nation's solidarity with South Africa's black leadership, first expressed during the anti-apartheid struggle and today continuing under majority rule.
But critics, including many other foreign physicians here, say such solidarity is coming at an increasingly high cost. They charge that Cubans enjoy unusual luxuries and rights not available to others. Indeed, foreign physicians, many of whom were toiling in outlying regions long before the Cubans arrived, are leaving in droves.
"We have no problems with the Cubans being here, but (health officials) should not bring anybody here at the expense of our existence," said Ahmed Sharif, a Bangladeshi physician who chairs a labor association of 1,200 foreign doctors, excluding Cubans.
Despite a constitution which promises open government, South African health officials refused to provide information on the Cuban partnership.
The Cuban embassy also turned down repeated requests for comment. Doctors contacted by The Herald said they were too afraid to speak without the embassy's permission.
Fueled by soaring crime rates and fears of racial integration, South Africa has suffered from a severe "white flight" since shortly before the black majority took power in 1994. A recent independent study found that more than 230,000 South Africans — many of them middle-class professionals — emigrated between 1989 and 1997. As many as 2,000 medical posts have stood vacant.
The doctors who do stay mostly work where the money is — treating wealthy whites and Asians in private practice. Sixty percent of local doctors cater to only 20 percent of the population, according to Mark Sanders, a professor of public health at the University of Western Cape.
Into the void stepped the Cubans, whose work Sanders called valiant and indispensable. In the KwaZulu-Natal region, for example, a rural clinic that has been without a doctor since 1993 suddenly received four Cubans, who arrived with a preventative health plan and an ultrasound machine.
"Many of them are doing a quite good job in very difficult conditions," said Sanders, who trains physicians in rural clinics. "Here you have doctors working in areas where South African doctors aren't going. If they weren't there, you wouldn't have anyone."
German has a similar partnership, but has only posted a handful of doctors. Cuba has the manpower: Called "symbols of the revolution" by Fidel Castro, many of these doctors are trained specifically for export to developing countries.
But more than any feelings of proletarian responsibility, Cuba's internationalist missions are prompted by a need for cash — both by the doctors and the government who sends them. So argues Julie Feinsilver, author of "Healing The Masses: Cuban Health Politics at Home and Abroad" (University of California Press, 1993).
The Cuban government takes 30 percent of its doctors' salaries, which range from the equivalent of $20,000 to $60,000 — less than their South African peers, but several times their salaries in Cuba, where doctors are paid on par with school teachers. And Feinsilver says international aid workers receive political brownie points on their return to Cuba, in the form of better jobs, housing and material goods.
"Today, hard currency is a necessity in Cuba," she said. "Those who have access to it, no matter how insignificant the quantity, live better."
Since the Cubans began work in South Africa, the number of non-Cuban foreign doctors has plummeted from 2,300 to 1,200, as South African health officials instituted harsh new regulations. In 1995, the government placed an indefinite moratorium on the registration of new foreign doctors and refuses to grant job security through extended work permits.
"On 24-hours notice, we can be told, 'We don't need you. You must go,'" said Pakistani physician Safdar Malick, head of anesthesiology at a 300-bed hospital about 75 miles south of Johannesburg.
In contrast, Cuban doctors and their spouses receive free airfare, lavish welcome banquets, several weeks of training, and free housing and transportation, according to government documents. A memorandum obtained by The Herald outlines a long list of goods with which regional health departments must equip each Cubans' apartment, including a television with satellite dish, an entertainment center, a pine dining room set and a 3-piece upholstered lounge set.
"We came here during apartheid and catered to the needs of the more oppressed areas," said a doctor from central Africa, who has practiced here for 11 years. "The Cubans came here and were given the red-carpet treatment and champagne."
Though probably overstating the reality of the Cuban program, this doctor's sentiment is common. Cubans frequently complain that their work goes unappreciated. They live in remote areas, use inadequate equipment and receive less money than their peers, yet the medical community and local press have accused them of everything from poor English skills to medical malpractice.
Doctors working in the outback must be jacks-of-all-trades, ready to handle anything from a breech birth to tuberculosis. While some Cubans are trained in primary care, Sanders said, many others imported to South Africa are schooled almost exclusively in specialized fields of medicine and ill-equipped for general treatment.
In the late 1990s, 21 malpractice claims were filed against six Cuban doctors in the Northern Cape, the country's largest province. One anesthesiologist was sent home after four patients died when he failed to follow proper procedure. The other doctors were cleared of the charges, and supporters blamed the malpractice allegations on anti-Cuban politics.
The Cubans are an effective stopgap remedy, Sanders said, but South Africans cannot rely on them forever. Health officials have instituted a mandatory community service program for recent medical school graduates, which places more South Africans in rural clinics. But though the personnel shortage is reduced, the program fails to solve the shortage of experience.
"When they get out to rural areas without all the fancy equipment and fancy tests and chain doctors above them, they have to have skills," Sanders said. "That kind of doctor, unfortunately, is not being produced by our system."