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AVANA — He knew as a child that he wanted to be a doctor, like his father. He went to medical school, became a general surgeon and ultimately a heart specialist. He practiced at Cuba’s premier cardiovascular hospital, performed heart transplants, and published articles in medical journals.

For this, Roberto Mejides earned a typical doctor’s salary: about $40 a month.

It wasn’t nearly enough, even with the free housing and health care available to Cubans, to support his extended family. So in 2014, Mejides left them behind, moving to Ecuador to earn up to $8,000 a month working at two clinics and performing surgeries.

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It’s a common story here, where waiters, cabdrivers, and tour guides can make 10 to 20 times the government wages of doctors and nurses — thanks to tips from tourists.

“Doctors are like slaves for our society,” said Sandra, an art student and photographer’s assistant who makes more than her mother, a physician. “It’s not fair to study for so many years and be so underpaid.”

Cuba is proud of its government-run health care system and its skilled doctors. But even with a raise two years ago, the highest paid doctors make $67 a month, while nurses top out at $40. That leaves many feeling demoralized — and searching for ways to improve their lives.

Some enter the private economy — by renting rooms to tourists, driving cabs, or treating private patients, quasi-legally, on the side. Thousands of others accept two-year government assignments to work as doctors abroad, collecting higher salaries for themselves and earning billions for the state, which helps keep the stagnant economy afloat. In fact, health workers are Cuba’s largest source of foreign exchange.

A few doctors, like Mejides, arrange foreign employment on their own, putting at risk their future ability to return to a government job in the health system back home.

“It’s hard to migrate and be alone,” Mejides said in Spanish, during a video phone call from Ecuador to a reporter visiting Havana in October. “It’s stressful. I am in the wrong place. I should be with my family in my country, working and being rewarded properly.”

Still, with his Ecuador earnings, he was able to buy his wife, two daughters, and two stepdaughters a $23,000 apartment in Havana, and he sends them $300 to $500 a month.

Roberto Mejides
Mejides shows photos of his wife and four daughters, dressed in Halloween costumes, who live in Havana. Stephen F. Dennstedt for STAT

Renting out rooms to make ends meet

While doctors back in Cuba grumble about their low pay, they usually find ways to make do.

Sandra’s mother, Nadia, a genetics researcher, earns about as much as she pays a cleaning woman to maintain her three-bedroom Havana apartment. Whenever she can, she rents one of those rooms to tourists for $40 a night, making more in two nights than she does from her monthly earnings as a doctor. She asked that her full name not be used to avoid any problems with the government.

The rental income allows Nadia to have a modestly comfortable life and to be able to buy fruits and vegetables at farmers markets. But a restaurant meal is a rare treat, and traveling abroad is impossible.

Still, she loves her work and the intellectual challenge of her research into genetic diseases. She said many Cuban doctors are committed and provide excellent service, in part because of the ways they have learned to overcome shortages of equipment and technology.

“We don’t have all the electronic tools, so we have to learn to do things other ways, to diagnose just by external examination,” she said, over a dinner of fish and rum at her apartment.

She’d like to earn more money, of course, and she understands why so many doctors, including many she knows, have chosen to leave Cuba.

“I’m not ambitious for money,” she said. “I get rent from visitors, and I get to live in Cuba. I have a nice house, and I’m happy with what I have. But I’m not a millionaire.”

Cecilia, a 60-year-old former nurse who also asked that her full name not be used, spent 25 years working in government hospitals and clinics. To adapt to the shortages, she learned to make inventos medicos — medical inventions — using a chair or bench to raise the back of a patient’s bed, for example, or cutting the tip off an intravenous line to fashion an oxygen feed to a patient’s nose.

But she became disillusioned by the chronic shortages and the stress she saw in both her patients and colleagues.

“The material scarcity is so overwhelming that it keeps people from dedicating all the passion, love, and brain power that they should to their patients in need,” she said, sitting in a rocking chair in her third-floor Havana apartment. “I was the one who had to face the patients and tell them we don’t have the drug that you need. It was very common. And I didn’t want to do that any more.”

Doctors and nurses “have the best intentions, but they face so many obstacles, there are so many things on their mind,” she added. “The doctor might be treating a patient but they are actually thinking: ‘When I get home, at God knows what time, what am I going to feed my kid?’”

She quit nursing in the early 2000s and later began to pursue her passion, doing hands-on alternative medicine that combines techniques of massage, kinesiology, magnetic therapy, and so-called floral therapy, which uses extracts of flowers and herbs as healing agents.

Her work with private clients, who come to her apartment, is permitted under a license for massage, the only form of healing work included on a list of government-approved private services and businesses. Working three days a week, she earns almost $120 a month “if all my appointments show up,” she said. “I use to make that in six months working at the hospital.”

Havana nurse
Cecilia makes far more providing alternative therapies at her home in Havana than she did as a nurse. Lisette Poole for STAT

A surplus of doctors

In the years after Fidel Castro seized power in 1959, Cuba invested heavily in education and science, training tens of thousands of doctors, nurses, and scientists. As a result, Cuba, a country of 11.2 million people, today has 90,000 doctors, the most per capita in the world.

About 25,000 of these doctors, along with 30,000 Cuban nurses and other health professionals, are working in 67 countries around the world. They earn about $8.2 billion in revenue for the government, according to a recent article in Granma, the official paper of the Cuban Communist Party.

The bulk of the doctors, about 20,000, are in Brazil and Venezuela. Over the last three years they provided treatment to 60 million Brazilians, mostly the rural poor, said Cristián Morales Fuhrimann, the Pan American Health Organization’s representative in Havana.

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Cuba receives about $5,000 a month per doctor from Brazil, pays each doctor about $1,200, and banks the rest, said John Kirk, a professor of Latin American studies at Dalhousie University in Halifax, Canada, who has researched Cuba’s program of medical missions. Most of the doctors’ shares are deposited in their Cuban bank accounts, requiring them to return home to collect it.

“Cuba has too many doctors, so their main source of hard currency is to rent out medical services,” Kirk said.

Once close allies of Havana, Brazil and Venezuela have been engulfed in political and economic crises that will cause them to reduce their use of Cuban doctors in the coming years.

That may lead Cuba to redeploy some doctors to other parts of the world, including the Middle East. In Qatar, an oil-rich emirate about as far from Cuba geographically and culturally as any place in the world, the so-called Cuban Hospital is fully staffed by 400 Cuban doctors, nurses, and technicians.

Cuba’s dispatch of doctors not only generates revenue, it is also an exercise in soft power that allows the country to spread its influence around the globe.

“It’s a major contribution to the health of the world,” said Morales. “They made a big difference in fighting Ebola in Africa, in the aftermath of Hurricane Matthew in Haiti.”

Some Cuban doctors working overseas have defected to the United States, aided by a policy launched during the administration of George W. Bush that permitted Cuban medical personnel to go to the US with their spouses and children. In its last weeks in office, the Obama administration announced it was ending the program.

Since the Cuban Medical Professional Parole Program began in 2006, more than 9,000 medical professionals and their family members were approved for admission to the US. In the past four years, the number of entrants spiked, reaching almost 2,000 for the fiscal year that ended Sept. 30.

The Cuban government and the Pan American Health Organization protested the policy as a form of poaching that undermined Cuba’s health system and impeded newfound cooperation between the US and Cuba. In a statement, Obama acknowledged that the program “risks harming the Cuban people.”

Cuban doctors are in demand internationally because they come cheap, are well-trained, and work in a public health system that is highly organized and well-run. In Cuba, primary care clinics are available in every neighborhood. Specialists in cancer, immunology, genetic medicine, and cardiovascular disease staff the hospitals. Life expectancy rates, which two generations ago were at Third World levels, are today roughly equal to those in the United States.

But the absence of so many doctors also provokes complaints from patients, who say it keeps them from getting the best care. They also grouse that they have to bring their own food and bedsheets, wait for appointments or medications — and provide gifts to doctors to ensure good treatment.

When the 61-year-old father of Concepcion, a young Cuban professional, was diagnosed with prostate cancer last summer, she used personal connections to enable her father to see a specialist promptly.

Concepcion, who asked that her full name not be used to avoid reprisals or damage to her professional standing, also provided daily gifts of food, cosmetics, and sometimes cash to doctors, nurses, and technicians while her father was hospitalized for a month in Holguin, a city in eastern Cuba.

“Doctors are used to receiving gifts,” she said. “You give the gift and the attention starts getting better. If you stop and the attention goes down, you go back to handing out gifts. You feel sorry for the doctors because they work really hard under bad conditions and you always feel like they’re not being rewarded.”

She estimated she spent about $500 on gifts and food, an amount she said would have doubled had he been hospitalized in pricier Havana.

Jose dos Santos, a Cuban journalist who needs regular treatment for his diabetes, said the care he receives is excellent. Bringing gifts to doctors “has become a habit because we know that the job doctors do needs to be better rewarded,” he said. “We don’t produce oil,” he added, “but we produce talent, and it makes sense that that talent is acknowledged and rewarded.”

In December, Roberto Mejides moved again, this time to Merida, Mexico, where he plans to work for the next four years. His income will be roughly the same as in Ecuador, but now he’s just 90 minutes by air from Havana. He hopes to bring his family to join him in the coming months,

“My hopes have always been the same, to work honestly and to provide my family with an adequate life,” he said. Someday, he added, he wants to return to Cuba: “It’s my country, my homeland.”

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  • I recommend Cuba Doctors for their good job globally.

    Is it possible to get health workers from Cuba to work in our mission hospital in Kenya to include physician’s, medical doctors,surgeons and obstetrician/gynaecologist?
    Thanks

    • The Kenyan government already threatened to import Cuban strike-breakers. Learn from what happened in Zimbabwe: Mugabe imported expensive Cuban doctors because he refused pay rises – which would have left them cheaper than the imported Cuban slave labor – and local doctors just packed up and left increasing the need for imported doctors and a higher bill.
      Now Zimbabwe is reduced to “poaching” doctors from the Congo and importing some from Algeria as they are cheaper than Cubans.
      The lowest paid Kenyan doctor gets now $15,000 a year. Brazil – one of the lowest paying countries – pays 4,300U$ a month so 51,600U$ a year ( Venezuela over $150,000) to the Cuban regime (of which Cuban doctors get very little). That is just for a basic doctor, not a specialist. At those prices Kenya would be better off giving in to the doctors demands of 100% pay rise. It actually would save money unless of course it hopes that South Africa would foot the bill as it did for Cuban doctors in Malawi.
      “Municipal health officials in Bahia said they provide free board and lodging to the Cubans, who get paid 800 reais a month in cash in Brazil. An additional 1,200 reais are paid to their families in Cuba, and 8,000 reais go to the Cuban government through the Pan-American Health Organization.”

      http://www.reuters.com/article/us-brazil-doctors-cuba-idUSBRE9B005720131201

      Shame on you for supporting feudal serfdom ans slave labor.
      “Fuedal Serfdom: The Fate of Health Professionals in Cuba”
      http://www.huffingtonpost.com/yoani-sanchez/fuedal-serfdom-the-fate-o_b_521920.html

  • This is just another example of why the U.S. should NEVER become a single-payer health care system. Doctors and nurses doing their best to care for patients are abused by their government. It happens in various ways in other single payer systems in other parts of the world as well. Socialism stinks!

    • No it doesn’t. Out present system stinks. Overpaid doctors and administrators, overpriced medicine from crooked pharmaceutical companies and dirtbags running the insurance companies. Tell me what’s wrong with socialism in Scandinavia?

  • And this is all. And Castro, hate him or love him, always deployed his doctors out to the world in any area with raging humanitarian need. This small island nation is amazing. It used to be about sugar, gambling, gangsters and night clubs. Now, Cuba is a MD dynamo, and their products need to be recruited and treasured.

    I loves this: so true
    Cuban doctors are in demand internationally because they come cheap, are well-trained, and work in a public health system that is highly organized and well-run. In Cuba, primary care clinics are available in every neighborhood. Specialists in cancer, immunology, genetic medicine, and cardiovascular disease staff the hospitals. Life expectancy rates, which two generations ago were at Third World levels, are today roughly equal to those in the United States.

    • Cuban doctor aren’t that “cheap”. Venezuela paid up to $150,000 a year of which the Cuban doctors themselves see nearly nothing. They get a small stipend of a couple of hundred dollars to “live on” where the are and up to $800 more at home in a bank account they can’t access from abroad. They are slaves. the effect of having 38,000 to 50,000 of doctors out of 75,000 rented out results in doctor shortages abroad and lots of the clinics you refer to are closed or understaffed resulting in suffering for the Cuban people. Most specialists are rented out so waiting lists and corruption (paying to get first in the queue) are rife. Cuban hospitals are lacking even the basic equipment and medicines. even bed sheets and food are lacking.
      As far as life expectancy: international experts and Cuban doctors that have fled the island have confirmed Cuban health statistics are manipulated for political reasons.
      You also are wrong about Cuba before Castro: it was the third developed nation in the Americas and even was beating countries like Belgium, France and Spain in lots of statistics of development.
      Don’t take my word for it:
      “Armando Hart, a member of Castro’s innermost ruling group, made the extremely significant observation that:
      . . . it is certain that capitalism had attained high levels of organization, efficiency and production that declined after the
      Revolution. . . (Juventud Rebelde, November 2, 1969; quoted by Rene Dumont, Is Cuba Socialist?)
      Theodore Draper quotes Anial Escalante, (before he was purged by Castro) one of the leading communists, who admitted that:
      …in reality, Cuba was not one of the countries with the lowest standard of living of the masses in America, but on the contrary, one of the highest standards of living, and it was here where the first great . . . democratic social revolution of the continent burst forth. . . If the historical development had been dictated by the false axiom [revolutions come first in poorest countries] the revolution should have been first produced in Haiti, Colombia or even Chile, countries of greater poverty for the masses than the Cuba of 1958. . . (quoted in Draper’s Castro’s Revolution: Myths and Realities; New York, 1962, p. 22)

    • Castro’s medical plan is no aid. It is trade. It is bringing in 8 to 10 billion dollars a year (biggest source of foreign currency) by using virtual slave labor.
      An example of your aid and the proof of near slave labor (indentured labor):
      “Municipal health officials in Bahia said they provide free board and lodging to the Cubans, who get paid 800 reais a month in cash in Brazil. An additional 1,200 reais are paid to their families in Cuba, and 8,000 reais go to the Cuban government through the Pan-American Health Organization.”
      http://www.reuters.com/article/us-brazil-doctors-cuba-idUSBRE9B005720131201

  • This is Castro’s enduring achievement, the amazing army of well-educated, well-respected Cuban MDs, Nurses, etc. Bring them here, we have an extreme shortage of primary care doctors in the US and Cuba, if it is smart, will continue to pumping out great MDs.

    • Cuban doctors aren’t that “well educated”. Cuban educated doctors have failed the certification exams in Costa Rica, Brazil, Pakistan, Chile, ….. in droves. Brazil set up a “remedial school” and Costa Rica sent them back to school. Costa Rica calculated that Cuba only gave 70% of the required courses for medical doctors in Costa Rica.
      Cuban doctors are blocked from emigrating even after their required 3-5 years of public service to pay for their education. 50 to 70% of them are rented out working like virtual slaves in Venezuela, Brazil, Qatar, South Africa, … with a pittance to live on and a small fraction (7 to 20%) of what the receiving country pays goes to an account in Cuba they can’t access. Their families are held back in Cuba to ensure their return and any doctor refusing a “mission” is struck off. Are you suggesting that the USA would agree to hire slave labor? US courts will strike this down as abuse. The regime should allow Cuban doctors their freedom after the “social service period”. Now a doctor that has 25 years of service theoretically has to work another 5 before his application to emigrate can be looked at. In reality the permission is never given and the doctor that had the guts to apply is sanctioned by either being struck off or sent to the worst possible posting.

  • Cuba is failing in the fights against Zika. As always the propaganda hides the facts. The Aedes Aegypti mosquito is everywhere and Zika has entered Cuba. If the vector is out of control and the disease is established there is no stopping it.
    See: http://zikacuba.impela.net/

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