New deal for diplomat doctors

Too many Cuban doctors didn’t want to leave SA. That, and absconding to other countries, were the main reasons why the Cuba-SA health deal broke down more than a decade ago.

But since Health Minister Aaron Motsoaledi and his Cuban counterpart Roberto Morales Ojeda have signed a new deal, it is believed the blood of the revolutionary doctor runs red again.

There has not been a regular influx of Cuban doctors to SA since about 2000.

That was five years after then-Health Minister Nkosazana Dlamini Zuma concluded a groundbreaking arrangement with one of the ANC’s firmest international allies.

During those years, more than 400 Cuban doctors came to work here, mostly in rural and marginalised areas, while SA and Cuba also co-operated in health research.

At the moment, there are about 140 Cuban health professionals in the country working in hospitals and clinics in eight provinces and as professors at the medical faculty at Walter Sisulu University in the Eastern Cape.

The new agreement, signed in Pretoria a fortnight ago, means Cuba will now provide 208 specialists for district-based support teams in the pilot phase of the National Health Insurance (NHI) programme.

There are 52 NHI districts, and each should get a team including an anaesthetist, obstetrician, gynaecologist, paediatrician and family medicine specialist. At just 27 000, there are simply too few SA doctors to fill the need. We need 65 000.

It’s a long time since the first 96 Cuban medical doctors were feted at a lavish government reception in February 1996, but the bilateral agreement on recruitment ended when too many decided to leave the programme. Cuban doctors opting out of the government-to-government agreement were free, in principle, to rewrite the SA-limited practice exam or, if they wanted to work independently, the equivalent of the SA sixth-year medical exam. But it wasn’t always that simple.

The earlier agreement had worked well for a number of Cuban doctors, who take on the status of international aid workers when they are posted outside the country.

Those with 10 years’ experience or more who worked in SA government hospitals and institutions were paid up to $1 000 a month – about triple their salaries at home.

Doctors in Cuba are paid the same as teachers, an amount estimated at $25 a month.

But while they may earn very little, Cuban doctors – who also get a $50-a-month stipend while they’re abroad – work with the experience of a widely-praised health-care system back home.

Medical care is free, life expectancy is 75 and the infant death rate is fewer than 10 per 1 000.

As part of the “doctor diplomat” system, Cubans were once among the highest number of foreign medical practitioners in SA – matching or even exceeding the number of SA doctors emigrating.

At the height of the old agreement, Cuba was providing the second-highest number of foreign doctors to SA at about 20 percent, while the highest numbers are still migrant doctors from Central Africa, at nearly 30 percent.

Doctors from Asia and the former Soviet republics account for about the same number as the Cubans.

There have been difficulties with the co-operation agreement, though.

SA has played the role of intermediary on the continent with the Cubans. Prominently, in 2004, an agreement between SA and Cuba saw more than 100 Cuban doctors sent to Mali, with SA giving financial backing.

A similar trilateral arrangement is in place in Rwanda.

But hardship measured the success. In 1996, just after the original agreement was signed, the Health Professions Council of SA (HPCSA) issued a moratorium on the registration of foreign doctors from other countries.

This was later lifted, but the government undertook not to recruit from the 130 developing nations under the G77 unless this was under a government-to-government agreement. Prominent deals have since been signed with Iran and Tunisia.

By as early as 1998, up to 25 percent of all public sector doctors in the country were foreign, and some analysts put that number at closer to 50 percent today, with the health department’s foreign workforce management programme running the process.

With the new agreement in place, the HPCSA will send a team to Cuba to assess applicants for registration, as doctors in Cuba are not as well-versed in disease control and surgical procedures as South Africans.

Cuban doctors tend to specialise, and are registered here to practise only under specific conditions.

Motsoaledi explains: “Cubans are trained in the community. It’s not an accident that Cuba has no malaria, that their HIV-Aids incidence is virtually zero, that they have little tuberculosis, that they hardly ever see meningitis. They virtually eradicated them through their primary health-care approach”.

The new inter-government deal came after a controversial R350 million economic assistance package to Cuba was ratified by a single vote by the portfolio committee on trade and industry early last month.

That package – which emanated out of an agreement President Jacob Zuma made in Cuba last year – sparked heated debate in Parliament.

The deal, aimed at helping Cuba improve its food security, includes a R100m “solidarity grant” which will not have to be repaid, as well as a loan of R250m. During his visit to Havana, Zuma wrote off all previous debt owed to SA.

Major trade between the two countries includes vaccines and other medical products.

SA and Cuba have also signed a memorandum of co-operation between armies, highlighting military health exchanges. But not all medical exchanges have gone well.

In 2003, a group of Cuban doctors lodged complaints of gross human rights violations with the Human Rights Commission (HRC).

The case of the seven doctors, dismissed in Limpopo, created a scandal. They claimed this happened after Special Assignment aired a documentary about their working difficulties, but the Limpopo health department said the doctors had opted out of the bilateral agreement.

At the time of the HRC complaint, the doctors had apparently either applied for permanent SA residence, had decided not to take annual compulsory leave home to Cuba or had refused to send their children back after they turned 15.

They faced deregistration by the HPCSA.

But Labour Court Judge DJ Pillay ruled in favour of an interdict preventing Limpopo from sacking the doctors, who said they had been harassed, threatened and their families thrown into disarray when they decided to opt out of the government-to-government agreement.

All had wanted to carry on working in public health.

It was in fact Mangosuthu Buthelezi, then the minister of home affairs, who supported the seven doctors, writing to then-Health Minister Manto Tshabalala-Msimang to say foreign nationals were not required to submit a letter of consent from their governments when applying for permanent residence.

There was even more pressure on the doctor diplomacy between Cuba and SA in the early part of the last decade. Although then-health minister Dlamini Zuma was decorated with the Friendship Medal in Cuba, there were more problems than just the seven doctors from Limpopo.

Another Cuban doctor faced dismissal from his job as an orthopaedic surgeon at Grey’s Hospital in Pietermaritzburg because he had resigned from Cuba’s Communist Party. Dr Mario Menchero had been in SA since 1998.

Yet another, paediatrician Dr Juan Elutil Yings, alleged he was evicted from his government-sponsored home, put behind bars and unfairly dismissed by the Eastern Cape Health Department when he converted to Islam.

Based at the Tayler Bequest Hospital in Mount Frere, he said it was after the co-ordinator on the Cuban-SA deal visited him and saw a picture of Mecca and Arabic scripture in his house that he received a letter giving him nine days to move to the remote Tafalofefe Hospital.

Apparently outraged that he would have to leave Mount Frere, he was then held by Home Affairs officials in Mthatha, where his work permit was allegedly cancelled and he was charged with contravening the Aliens Control Act.

The Labour Court generally upheld doctors’ complaints, with the government being told it had to keep them on the payroll. They were needed.

Until the breakdown of the original Cuban deal, the revolutionary doctor was a significant source of solidarity between SA and Cuba.

Medical brigades have seen thousands of Cuban physicians sent mostly to developing nations where there is free health care for disadvantaged communities since the 1970s. But there have been defections, and these have been encouraged by the US Department of Homeland Security since 2006 when it announced it would allow Cuban medical personnel conscripted to study or work in another country to enter the US under the Cuban Medical Professional Parole Programme.

Apparently there have been more than 1 600 defections since then, out of the dozens of countries where Cuba sends its medical personnel, earning billions of dollars a year.