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Investigation: Public Health in Cuba

DIARIO DE CUBA reveals the secret negotiations between Havana and Brasilia for the creation of Más Médicos

Telegrams from the Brazilian embassy in Cuba reconstruct the negotiations with Brazil for the creation of the Más Médicos program.

San Pablo

Telegrams from the Brazilian embassy in Cuba reconstruct the negotiations with Brazil for the creation of the Más Médicos program. Classified as confidential and kept secret for five years, these telegrams belie part of the official story told to Brazilians.

The documents show, for example, that the program was offered by Cuba and was already negotiated a year before then-President of the Republic, Dilma Rousseff, presented it in response to the June 2013 protests. The negotiations were kept secret, to avoid reactions by the medical community. At these meetings, Cuba made the demands now criticized by President-elect Jair Bolsonaro, and whose possibility of cancellation spurred Cuba to abandon the program in Brazil.

So that the approval of the National Congress would be unnecessary, Brazil decided to triangulate the business: the Brazilian Government would pay the Pan-American Health Organization (PAHO), which would hire the Cuban Government, which, in turn, would hire the doctors.

In fact, when Cuban doctors prosecuted Brazil in court, the Brazilian government responded that it had no direct relationship with them.

In October 2011 Cuba created corporations, private companies linked to the Cuban government. One of them was Comercializadora de Servicios Médicos Cubanos (CSMC), which exported medical workers and supplies. Medical services are one of the main components of Cuba's foreign trade agenda, with agreements in more than 60 countries.

Five months later, in March 2012, a CSMC delegation prospected the Brazilian market. They visited the states of Amapá, Bahia, Paraíba and the Federal District. On April 20, Tomás Reynoso, vice-president of the CSMC, offered the Brazilian embassy everything "from the sending of doctors and nurses to consulting on the construction of hospitals, and the development of health systems," at "advantageous prices," according to Alexandre Ghisleni, at the time Brazil's Chargé d'Affaires in Havana.

Cuba's Deputy Minister of Health, Marcia Cobas, then went to Brazil. At an official meeting in May, at the Ministry of Development, she offered 1,000 doctors in 2012. She presented the vacancies for doctors in the Amazon, "with an initial salary of 14,000 reales," due to a lack of interest among Brazilians. She spoke of the cooperation agreement signed under the government of President Fernando Henrique Cardoso, and said that she would only forge a new alliance if Brazil prevented the doctors from staying in Brazil at the end of the program, as had happened with 400 professionals in the 1990s.

In June the Brazilian Health Ministry organized a visit to Havana to discuss the issue. According to the Brazilian embassy in Cuba, the project was "initiated in a cautious manner, in the face of concern about the repercussions from the arrival of doctors in Brazil's medical community."

The delegation was headed by Health Ministry Secretary Mozart Sales. Alberto Kleiman, then international advisor to the Ministry of Health, also participated in the delegation. Today Kleiman is the Director of International Relations and Partnerships at the PAHO.

The documents show that the Brazilian delegation accepted all Cuba's demands, and that the biggest hurdle was the financial aspect. Brazil and Cuba only agreed on the figure that each doctor would receive.

"The Brazilian side proposed the amount of $4,000 ($ 3,000 for the Cuban government and $1,000 for the doctor)," the office reports regarding the meeting. "The Cuban side, in turn, said it expected to receive $8,000 per doctor, but later proposed $6,000 (5,000 for the Cuban government and 1,000 for the doctor)."

Cuban authorities demanded that all doctors' evaluations be carried out in Cuba, and that Brazil restrict itself to "familiarizing doctors with the language, procedural and administrative practices, and legislation."

A draft of the contract, which does not appear in the documents obtained, but was discussed at the office of Ambassador José Eduardo Felício, stated that disagreements could only be settled by the "Cuban Court of International Commercial Arbitration, under its procedural rules, in the City of Havana, and in Spanish."

Brazil accepted all these points.

The idea was to sign a commercial contract for the purchase of medical services, and not an agreement between governments. According to Felicio, a formal agreement "may have to be submitted to the National Congress, where, incidentally, it would generate controversy."

In November the Embassy noted that 20 Brazilians would go to Cuba to "give two-week courses to doctors on the Brazilian Health System and its organization." On the eve of Minister Alexandre Padilha's trip to Cuba, in December 2012, the name of the "Más Médicos" program was already used.

Almost everything had been negotiated, except for two points. One was the price. Cuba dropped to $5,000 per month per doctor, but the Brazilian government did not want to pay more than $4,000. The second point was the legal framework. Without an agreement approved by the Brazilian National Congress, it would be difficult.

It was precisely at this time that the PAHO intervened as an intermediary, "characterizing the contracting of services as cooperation in the medical sphere," Ghisleni emphasizes. Cuba did not like it at all: the resources would go through Washington, where the PAHO is headquartered. Padilha then proposed that the resources be transferred between the offices of the organization, without going through the US.

The first signs of the Más Médicos program in Brazil arrived at the beginning of 2013. In January the leader of the Government in the National Congress, Senator Eduardo Braga, told mayors in the Estado de Amazonas that Dilma would allow, using provisional measures, foreign doctors to work in the country. In March, Padilha stated, on the Jô Soares program (at the time the most important talk show on Brazilian television) that foreign doctors could be hired.

The reaction by medical entities, as the telegram predicted, was swift.

On April 4, 2013, representatives of the Federal Council of Medicine, the Brazilian Medical Association and the National Federation of Physicians went to Brasília (Federal Capital) to protest these measures. According to participants consulted for this report, Dilma did not confirm anything, but neither did she deny the information. Padilha and Mozart Sales, who negotiated in Cuba, were present.

Back in Havana, on April 23, 2013, a meeting was held to finalize the contract, documented at a new office of the Brazilian Ministry of Foreign Affairs. Representatives from Brazil, Cuba and the PAHO participated. On this same evening, at a meeting with the National Association of Mayors, Dilma defended the recruitment of foreign doctors to work in Brazil.

Three days later the first version of the 80th cooperation agreement between Brazil and PAHO, the basis of the Más Médicos program, would be signed, but without the official name, which would not appear until after July. Until December, hiring was still being discussed. At that time, at least on paper, the program was classified as an educational project.

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