Faulting the cure in Brazil

Health system needs resources, doctors say, not imported physicians

Seth Kugel / New York Times News Service /

Published Jul 18, 2013 at 05:00AM

São PAULO — Every weekday morning dozens of government vans, ambulances and battered sedans marked with the seals of towns across São Paulo state drop off their passengers at Santa Casa Hospital and others in the metropolitan area.

The drivers set out as early as 3 a.m. to transport residents of far-flung cities and towns, residents who have waited months or sometimes years to see a specialist, have surgery or get a CT scan, services not available at their spare clinics back home.

On a recent day, Nilson Esteves, 32, traveled from rural Pedro de Toledo to pick up test results; he has been waiting three years to have a benign tumor the size of a tennis ball removed from his neck. Georgina Barbosa, a 70-year-old widow, came from Capivari after waiting three months to get treatment for bladder stones. “If it was going to kill me, I’d be dead already,” she said.

Barbosa is painfully familiar with the perils and inadequacies of Brazil’s public health system, a focal point of the protests that shook Brazil last month. Both of her sons died in their 40s, one from a heart ailment and one from diabetes, and she lost vision in one eye during a recent operation. Her frustrations are reflected in a national poll from late June in which 48 percent of respondents said they thought health care was Brazil’s biggest problem. (Education was second at 13 percent.)

But President Dilma Rousseff’s overall efforts to respond to the protesters’ concerns have disappointed many Brazilians, and her health care proposals have particularly antagonized many of the country’s doctors. When Rousseff spoke to the nation during the protests, her main message about health care was that Brazil would “bring in thousands of foreign doctors to expand the care provided” by the public health system.

The outcry from Brazil’s medical establishment was immediate, including protests and talk of legal action and strikes.

When she formally announced her plan last week, Rousseff hastened to clarify that her More Doctors program would focus not on recruiting foreign doctors but on improving care in rural and underserved urban areas and increasing government spending on health care. Efforts would be made to fill openings with Brazilian doctors first, she said.

A dozen doctors interviewed across São Paulo last week, however, remained focused on the issue of foreign doctors. Their almost unanimous conclusion: Resources should be the top priority.

“What we have is not a lack of doctors but a lack of infrastructure and supplies that would allow for a better distribution of doctors where they are needed,” said Dr. José Luiz Leão, 45, a surgeon.

Leão started his career as the only doctor in São João do Araguaia, a town of 12,000 in the Amazonian state of Pará, but he left in frustration, he said, over the lack of equipment for even basic surgery and insufficient supplies of essential antibiotics.

He now oversees the Saturday shift at the public Antonio Giglio Municipal Hospital, in Osasco, a largely poor city of more than 700,000 that borders São Paulo to the west. His working conditions have improved, but not much. The shabby emergency room and intensive care units, where doctors make as little as $25 an hour, are low on basic supplies. Patients often languish for days in the emergency unit, nearly naked and exposed without hospital gowns or curtains.

Brazilians who can afford it pay for private care. When a former Osasco mayor, Celso Giglio, who built the hospital named for his father, was severely injured in a car accident, the ambulance bypassed Osasco’s hospital and took him to Albert Einstein Hospital in São Paulo, a more costly, private institution. That prompted a flurry of morbid jokes from Osasco residents.

The Health Ministry has defended the need for foreign doctors, noting that Brazil has fewer doctors per capita than Argentina and Uruguay, and that the shortage is particularly severe in the Amazon and northeastern states where many of the newly recruited doctors would go. The ministry also said many countries, including the United States, regularly sought to attract foreign doctors.

Not all doctors oppose the president’s plan. Antônio Augusto Dall’Agnol Modesto, a family physician who works at a bustling public clinic in São Paulo, said that while he found the idea of recruiting foreign doctors problematic, he did not like the way the physicians’ organizations were making their argument.

“You can be against Dilma’s proposal,” he said. “But not just because the doctors are foreign nor because it is an emergency program, but because it was not tied to adequate long-term projects.”

Dall’Agnol Modesto said Brazil needed more family doctors and general practitioners because patients swamped specialists with routine issues, increasing the wait for those with more severe problems.

But rural clinics, the government argues, need any kind of doctor. So last Monday, when Rousseff unveiled her plan, she also announced that more medical schools would be established to train thousands of new doctors. Also, their training will be extended to eight years from six, adding a “second cycle” of two years during which students would work in public service posts. That could add up to 36,000 to the public health service by 2021.

The medical establishment again erupted in protest. Several organizations called the plan “questionable,” and the National Federation of Physicians described it as a “form of exploitation.”

The Health Ministry said the measure was not a social service requirement but an important element of the students’ training and exposure to the realities of the health care system. “We believe that it is important that Brazilian doctors are trained within the public system, much as they are in England or Switzerland,” said Mozart Sales, the Health Ministry official who will oversee the program.

Dall’Agnol Modesto, the family doctor, said he was torn. “It’s been tried in other countries,” he said. “It seems to be an opportunity. But on the other hand, it’s very dangerous to send recently graduated doctors to distant posts without resources.”