Brazil’s New President Isn’t Even in Office Yet and He’s Already Damaged Our Health Care

Cuban doctors heading home in Brasilia last month, after criticism by President-elect Jair Bolsonaro of Brazil prompted Cuba’s government to sever a cooperation agreement.CreditCreditAdriano Machado/Reuters
Cuban doctors heading home in Brasilia last month, after criticism by President-elect Jair Bolsonaro of Brazil prompted Cuba’s government to sever a cooperation agreement. Credit Adriano Machado/Reuters

A few weeks ago, the Cuban government announced it would withdraw from the Brazilian medical program Mais Médicos, which sends doctors to remote, underserved areas in Brazil. It’s estimated that millions of citizens could be deprived of primary health care after the departure of roughly 8,600 Cuban doctors from the country. The decision was prompted by demeaning remarks made by Brazil’s right-wing president-elect, Jair Bolsonaro.

Mr. Bolsonaro has repeatedly questioned the qualifications of Cuban doctors: “We have no proof that they are really doctors and able to take on these functions,” he said recently. This is false: All foreign doctors working for the program need to present their degrees and their licenses to practice medicine abroad. However, they are exempt from taking a national exam to revalidate their degrees while serving in the program; Mr. Bolsonaro intends to remove this dispensation. He has also repeatedly questioned the ethics of Cuba’s doctors-abroad program, saying that the doctors should be able to bring their families to the country and that they should receive their full wages directly from the Brazilian government. (Because all Cuban doctors work for the state, the government keeps around 70 percent of their salaries, and families are only allowed to visit them.)

Mr. Bolsonaro’s objections are both idealistic and ideological: He may well want to see Cuban doctors get paid, although it’s difficult to believe that these humanitarian impulses don’t have something to do with his feelings toward Cuba’s Communist government. Perhaps, to some his requirements will even seem reasonable. But the problem is that the Cuban government, which understandably took Mr. Bolsonaro’s comments as “derogatory and threatening,” has already begun bringing health care workers home. As a result, Brazil’s indigenous population will reportedly lose 81 percent of its doctors. More than 1,500 municipalities could be deprived of all medical assistance. (As of late last month, the Health Ministry said it had filled many of the vacancies, though it was not clear that new doctors would be prepared to go into rural areas.)

Through his remarks, Mr. Bolsonaro, who has not yet taken office, has managed to damage a program that has been praised by two independent bodies and by the United Nations Office for South-South Cooperation for having “contributed to a lower infant mortality rate and a decrease in hospitalizations as a result of the availability of primary health care.” He has no plan to patch things up. Indeed, this may be the first official demonstration of Mr. Bolsonaro’s style of government: strong opinions, but no actual solutions. And when it comes to our health care system in particular, this style of governance is dangerous.

In Brazil, health care has been a right for every citizen and a duty of the government since the adoption of the 1988 Constitution. Our Unified Health System, better known as S.U.S., or Sistema Único de Saúde, provides full medical care, free, for everyone. Universality and equity are the system’s two basic principles.

S.U.S. is impressive, though, of course, it’s far from perfect: Hospitals and health centers are usually crowded, and ill-equipped to respond to the ever-increasing demands. There are often long waiting lines for exams, surgeries and appointments; patients have died in hospital corridors or while waiting to see a doctor. That’s why 24 percent of Brazilians pay for private medical insurance, according to Brazil’s regulatory agency for private health insurance. Others rely on low-cost clinics or pay extra for appointments and treatments.

But it does matter that health care is considered a right, rather than a privilege. People persistently demand higher standards of care, because that’s their constitutional prerogative. And though the quality of the services provided may be uneven, there have been many examples of great benefits obtained through public expenditure. Thirty years into the creation of S.U.S., we already have some excellent projects to showcase.

A good example is our national immunization program, one of the best and most complex in the world. It offers 19 vaccines free for children, adolescents, adults and seniors, including pregnant women and people with special health conditions (such as allergies or low immunity). From 2002 to 2012, the program reached an average coverage level of 95 percent among children for most vaccines. It helped eradicate smallpox in 1971, and polio in 1989. It is also finding its way to a state of self-sufficiency: Most vaccines are produced in national laboratories, thus ensuring a stable and affordable supply.

Every month I walk half a mile to vaccinate my baby daughter; we are always promptly assisted by a nurse. The service is efficient, reliable and friendly. I myself have a duly filled, lifelong vaccination record to boast about.

Another area of excellence is our organ transplantation system. Brazil maintains the largest public program in the world, with about 27,000 transplants performed last year — 96 percent of them carried out by S.U.S. In number of transplants, we are second only to the United States.

A friend of mine has familial amyloid polyneuropathy, a rare disease in which the liver produces abnormal proteins that accumulate throughout the body. It leads to serious sensory, motor and autonomic nervous system impairments, and can become fatal 10 years after the onset of symptoms. She lost her mother, grandmother and one uncle to the disease. But now it’s different: When she started to feel ill five years ago, she joined the waiting list for a liver transplant. Months later, she underwent surgery in a state-of-the-art hospital and received a new organ. Everything was financed by S.U.S., including post-surgical treatment with immunosuppressants and follow-up appointments.

Brazil’s S.U.S. is also internationally renowned for starting a pioneering H.I.V. program that has provided free universal access to antiretroviral therapy for all patients since 1996. The project has drastically reduced AIDS-related mortality and morbidity, including mother-to-child transmission of the virus.

What does Mr. Bolsonaro say to all this? He’s been dismissive, not only of the efficiency but the quality of our health care system. His proposals for reforms have been contradictory. He claims there will be no increase in the public health budget, but then proposes costly innovations like implementing a national clinical data registry and creating a federally funded career path for doctors. He has also suggested that clinicians in the private sector could be incorporated into the public health service, a change that would require the use of subsidized reimbursements. This is not necessarily bad, but it would be costly — and most important, Mr. Bolsonaro doesn’t seem to have a clue on how to accomplish any of it. But as his remarks about Cuban doctors show, that would hardly stop him from stumbling in and ripping apart what’s currently working.

It is clearly worth working to preserve S.U.S. We cannot lose what we have accomplished so far. If our president-elect is fine with losing the services of thousands of Cuban doctors, he needs to find a new way to deploy good medical professionals to the most underserved areas of our country. And if he doesn’t have all the solutions for improving health care, at least he should make the commitment to maintain public spending while seeking to improve efficiency — in other words, to not make things worse.

The foundations for great public health care in Brazil are already in place. It only takes political will to maintain and expand this remarkable system. Let’s hope it can survive the next four years.

Vanessa Barbara, a contributing opinion writer, is the editor of the literary website A Hortaliça and the author of two novels and two nonfiction books in Portuguese.

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