Doctors in Exile´s Alliance

Doctor's Reserve

Cuban medicine is prestigious and is praised by many. Since 1963, more than 100,000 health professionals have collaborated with other nations through the so-called medical brigades. But the island has also been criticized for the significant withholdings in doctors’ salaries during international missions and for the working conditions of health professionals. In addition to this complex situation, sometimes members of the brigades make the difficult decision to stay in the country where they have been working against Cuba’s orders.

The problems faced by Cuban doctors disaffiliated from the brigades are numerous. The island relies on them to establish and/or strengthen diplomatic ties with other countries. Therefore, it is an important issue for the Cuban foreign policy agenda. On the other hand, specific bilateral agreements are signed with each country, significantly influencing the doctors’ employment situation and the possibility of returning to work. In the case of Brazil, for example, the vast majority of Cuban doctors arrived in the country between 2013 and 2018 through a program called Mais Médicos whose objective was to fill the lack of doctors in the rural municipalities and on the outskirts of the big cities in Brazil. There were few options to continue practising their profession for the doctors who decided not to go back to Cuba when the program ended. Cuba retains the documentation and diplomas of doctors who stop working for the island’s government. From one day to the next, these professionals are faced with a double vulnerability by becoming stateless and unemployed. At first, the only two ways to be able to recover a job were the judicial process, long, expensive, individual, or the pressure through political organizations. The Doctor’s Reserve association was created with the active support of Prodie Santé to find a third path of common, non-confrontational and non-political action.

At least half of the world’s population is deprived of essential health services, according to the 2017 report of the World Bank and the World Health Organization. In 2013 the WHO warned us of the planetary deficit of 7.2 million professionals to cover the world’s health needs, an alarming and increasing figure, which should reach 12.9 million in 2035, according to the organization’s estimate. In this context, and considering the new and recent needs caused by the COVID 19 pandemic, it seems important that quality doctors with solid training and extensive professional experience can practice. Prodie Santé has teamed up with Doctor’s Reserve to make that dream come true. The association’s objective is to connect Cuban medical professionals located in different countries on a single platform to a global network that provides information about the validation of academic titles, provides international job offers and fundraising for different projects in the health sector. Prodie Santé wants to contribute to the concept of health as a universal good and, at the same time, guarantee good living conditions and decent treatment in line with human rights for doctors.

There is a great diversity of paths within what we could call the community of exiled Cuban doctors. Nevertheless, it is important to understand the common points between them: The excellent work and professional experience they have, their human qualities and their difficult personal trajectory. Therefore, we will describe and explain the specific knowledge that makes Cuban doctors a fabulous resource for any country. After that, we will present a series of portraits to raise awareness and facilitate a cross-sectional understanding of their journey.

I) Characteristics of Cuban medical training

In 1978 the International Conference on Primary Care held by WHO and UNICEF in Kazakhstan was the beginning of a strategy to achieve a better level of global health. In Cuba, this resulted in the implementation and generalization of the family doctor model. In 1985, a high percentage of the graduates were oriented towards a new speciality that promotes health, prevents risks and illnesses, and rehabilitates disabled patients: the Medicina General Integral (MGI). The new approach is based on the idea that there is an unbreakable bond between a person and their social context. It was implemented through the Primary Health Care system (PHC) to apply a new Clinical-Epidemiological method in which individuals are considered globally, connecting people with their most direct context: the family, the community and the environment. It is globally known as the biopsychosocial approach.

These doctors know how to work in poor, isolated, complex areas and they prepare plans adapted to local problems, develop prevention and training programs and carry out studies on medical problems in the region where they work. They practice community medicine, epidemiology, family medicine, and emergency medicine. A single Cuban doctor can take care of about 3,000 inhabitants. No doctor in the world has those capabilities, it is a Cuban specificity.

Comprehensive General Medicine is the sum of several specialities.

• General medicine and internal medicine
• Family and community medicine: Prevention, Community Health, Family Health, Public Health (epidemiological surveillance, control measures for infectious diseases, emerging and re-emerging diseases, pandemics, etc.), Nutrition and Dietetics
• Psychiatry:
• Ophthalmology
• Dermatology
• Natural and Traditional Medicine
• Use of the clinical-epidemiological method (Evidence-based medicine): Application of therapeutic approach techniques with a preventive approach

In addition to its medical competencies, the MGI has other professional competencies such as:

• Research (ASIS). It is descriptive observational research, carried out by the MGI, to characterize the health status of a population, carried out as preliminary work to understand the terrain, that is, the space, city, town, and region. It is a tool used to facilitate decision making and it makes it possible to detect health problems and create action plans to solve them. It uses variables like the elements that determine the health status of a population:
-Lifestyle.
-Human biology.
-Environment.

Another skill of the MGI is pure and simple Medical Assistance. The most classic and essential aspect of medical work covers the fields of Pediatrics, Obstetrics-Gynecology, Geriatrics, Medical Emergencies, Epidemiology, Mental Health, and Rehabilitation.

• A Teaching-Educational Work is also integrated into the MGI program, through the practice of the medical specialist as a teacher, both in the undergraduate and postgraduate processes.

And finally, the management of health systems, which is the administrative and management aspect of the Cuban doctors’ expertise. This allows for better control of the processes and the way of planning, organizing, directing, and controlling the different stages of the MGI.

The advantages offered by the MGI for a city, state, country are many:

-They are multi-specialist doctors who have a transversal, multidisciplinary and holistic approach to their mission.

-It is the only specialist designed to modify and impact the epidemiological profile of a particular population.

– They reduce considerably perinatal, neonatal and late natal maternal-infant morbidity and mortality, as well as general morbidity and mortality due to avoidable causes.

Considerably decreases the morbidity and rate of complications due to chronic diseases and the rate of consequent problems such as deficiencies or disabilities.

-Decongest health systems, reducing the flow of people to secondary care. This means that they drastically reduce the demand for emergency services.

-They are trained to carry out educational work and health promotion, analyse the epidemiological situation and propose solutions.

-They are an infallible tool tested to deal with extreme situations like epidemics and climatic catastrophes, etc. The examples are numerous, but the most recent case is the effectiveness of the MGI in the fight against the COVID-19 pandemic in the world.

II) Portraits of Cuban doctors

Exiled Cuban doctors often do not want to share their personal stories. Their delicate situation does not make it easier to talk publicly about it. Nevertheless, the people who have agreed to participate in this series of portraits chose to trust us, and we feel truly privileged to have the opportunity to share with our readers a little of these very particular trajectories, pieces of life like puzzles where the body and the mind are in one geographical place and the soul in another land.

The exile of the invisible

Yuri’s first assignment took place in East Timor. He was 23 years old and had just graduated. Yuri always wanted to become a doctor, “ever since I can remember,” she insists. “My ideas were progressive, and I always considered myself a left-wing person.” Her dream was to participate in medical missions in Africa. Her first job abroad was difficult for many reasons: the political and social circumstances of a country victim of a dirty and violent conflict, like every war, and because of the general conditions of her stay. She was locked up with other Cuban doctors, unable to go out, make friends, or contact the outside world besides her daily medical consultations. The mission coordinator held her passport so that she couldn’t go anywhere. Not for a few days, not for a weekend, nothing. “But we’re not robots,” Yuri says while shaking her raven black hair. Even with the few contacts they have through work, doctors are inserted into a community, into a country, and sometimes they adopt their culture, learn their language, and fall in love. Little by little, the bonds they have formed bring them closer to the land they live in.

Cuban doctors are not ordinary doctors. Many people have heard of them through the famous missions such as the governmental program Mais Médicos in Brazil or the work of the medical staff that Cuba has sent to various countries during the pandemic. They practice “Integral general medicine”, a holistic, humanistic medicine connected to the cultural and social environment. These super-doctors carry out prevention and epidemiology work and combine different specialities such as paediatrics, gynaecology, or emergency medicine.

Anidys is an intensivist doctor and has worked in Venezuela and Brazil. She tells me that when she graduated in 1997, her fellow students and herself thought their medicine professors were so brilliant that they gave them the nickname “the magicians.” She remembers that one of them could diagnose her patients just by looking at them. They called him “the wizard”. Anidys laughs, but sometimes there is infinite sadness on her face. When she arrived in Brazil after the “Venezuelan trauma”, she was impressed by the quality of life. Indeed, the bilateral agreements signed between Brazil and Cuba favoured somehow better living conditions for her compatriots, and she began to allow herself to dream. In the first hotel where she stayed with 800 Cuban doctors who were waiting like her to be sent to different places in the country, she was very impressed by what she considered at the time a form of luxury: The hotel, the buffets, “I could eat the delicious food but all I could think about were my starving kids back in Cuba.” Finally, she was sent to a small and remote city. She fell in love with the region, her people, and a man. When she decided not to leave and stay in the Mais Medicos program but freed herself from her “contract” with Cuba that took 70% of her salary (she only received 2,976 reais of the 11,800 reais that the Brazilian government paid for her work), it was tough. “Why do they pay you so little”, asks Anidys innocently? “Many doctors would stay if they received higher percentages of their salaries.”

According to official figures, the doctors who broke ties with Cuba are between 50,000 and 90,000. They all want to continue working, but Cuba confiscates their documents and diplomas. They cannot return to their country or see their families. Nevertheless, they represent an enormous potential in terms of global health. In August 2020, the first Cuban association of doctors outside the island was registered in Brazil. It is called Doctor’s Reserve, and it is entirely apolitical.

At Prodie Santé we know that there are no similar stories in exile. On the contrary, each person, each doctor, has their path, sometimes difficult and with no possibility of turning back. When you ask the president of the association of Cuban doctors, whom everyone calls Osmani, why they felt the need to create this organization, he replied: “To stop being invisible.”