Dilma and the Doctors

Last night, we scored another victory. The Federal Chamber of Deputies voted 430 to 9 against proposed constitutional amendment PEC 37 that would have gutted the Public Ministry’s ability to independently investigate crimes and wrongdoing by public officials. While I do not believe for a second that all of those “no” votes were sincere, I do give credit to the people in the streets for this. Having won another round, let us turn to the subject at hand: health care.

During her speech to the nation last Friday evening, Pres. Dilma Rousseff offered a series of platitudes, made some vague promises and mentioned a few ideas for action that she would undertake in response to those protesting throughout the country. One, a plebiscite to elect a constitutional convention to deal with political reform has already been largely set aside. Another,  her proposal to import physicians to help counter inadequacies in the public health sector, is being greeted with a large degree of skepticism. (Plans previously announced in Congress talk about bringing in up to 6,000 doctors from Cuba and other countries.)

The public’s response to this is perhaps best summed up by an internet meme that goes something like this, “Where are all of these new doctors going to treat their patients? In stadiums?” Another photo making the rounds shows Dr. Alex Araujo’s office in rural Minas Gerais (see accompanying photo). It is in a space which also serves as the local school’s library and kitchen. You can readily see cracks in the walls, a two-burner cook stove with a small gas tank next to it, numerous plastic pails, buckets and other types of containers, a storage shelf in the corner that seems to double as a book case, an extremely small wooden table behind which Dr. Araujo is sitting, and a chair in which we see a patient. There is also an open window that appears to have no glass in it.

A large part of the skepticism greeting Pres. Rousseff’s initiative to improve the country’s public health system (SUS – Unified Health System) arises from its crumbling infrastructure and the corruption within it which (like with many other public services) further diminishes its already inadequate resources. In other words, we need to improve what we already have on the ground before we bring more doctors into the system. If we don’t, where are they going to work?

Don’t get me wrong. I really like SUS. We don’t have anything like it in the United States. With all of its failings and all of its problems, even the poorest in this country are treated free of charge. They will be attended to – if there is a clinic within a reasonable distance and if it is staffed, of course. (We won’t even ask that it be adequately staffed at this point. That’s an altogether different question.) Here, for instance, you won’t be driven into bankruptcy if you develop cancer. We cannot say the same thing back home.  One of the reasons my family and I came back to Brazil was the availability of good medical care at an affordable price. I’ve already stated elsewhere that my wife and children benefit from private health insurance and, for a variety of reasons, I rely on SUS. I have had no complaints, but my situation is not the norm. I want to see SUS benefitting everyone in this country because most of the population does not have the means to pay for private health care.

Let’s take a look at a few numbers. According to its own statistics, 80% of Brazil’s population depends on SUS. That means SUS is the only option available for almost 160 million of Brazil’s 196 million people.  (Remember that over 72% of Brazilians make US$605 / month or less – mostly much less. It is their only option because private health insurance is out of their reach. Without SUS, they would have no access to health care at all.) Roughly 130 million people have access to SAMU (Mobile Emergency Service), which means they can take advantage of services analogous to EMS (Emergency Medical Services) in the United States. That population is essentially concentrated in urban areas, which also means that people in rural areas are not as well served, if they are served at all. In a similar fashion, the bulk of SUS’s six thousand hospitals are located in urban areas, as well as their 45,000 clinics. There are, however, a couple of problems. First, the rural population is largely left out of the loop and, secondly, what infrastructure there is, as stated earlier, is poorly maintained and understaffed. SUS has an extremely difficult time attracting doctors, particularly young doctors at the beginning of their careers, to rural areas. When you also consider the facilities, or rather, the lack of facilities awaiting them, coupled with extremely low pay, it is a small wonder there are any doctors willing to work in SUS in the first place.

For an example of a rural facility, all you have to do is reread my description of Dr. Araujo’s clinic above or just look at the accompanying photograph. Facilities in urban areas are hardly any better. The news media has been having a field day of late showing legions of broken down ambulances that have been scrapped due to little or no maintenance, warehouses filled with defunct hospital furniture and equipment. They are also reporting on under staffing. News stories abound, telling drastic tales of massive waits in grossly understaffed emergency rooms, about sick and injured patients who have to wait for hours on end to be tended to, insufficient beds, people being given IVs that are suspended from nails pounded into walls while they sit on wooden benches or, if they are lucky, metal folding chairs, patients stuck in rickety wheel chairs because the stretcher they should be lying on simply doesn’t exist – and, from time to time, patients dying while they wait. All of this makes for sensational journalism – and that sells, doesn’t it? Unfortunately, the nations’ journalists don’t have to look far to find something to report on.

And the doctors? What of the doctors? How do you attract good doctors when the average pay in SUS is US$884 per month.  (Average salaries per state range from $329 to $1,883. Those on the lower end of the scale are often in rural areas.)  How do you attract doctors to horribly under served rural areas when, in addition to the paltry salaries we have already mentioned, the working conditions are on par with – or even worse – than those Dr. Araujo faces day in and day out? Nevertheless, all of the doctors I have met in Brazil are qualified, highly trained professionals. Let me repeat that: they are qualified, highly trained professionals who, at least in the public sphere, are also used to working under adverse conditions. When the fancy equipment breaks down in US hospitals, our doctors often don’t know what to do until a replacement unit is found. SUS’s doctors don’t have that luxury. They often don’t even have the equipment. They have to practice medicine based on their knowledge, training and experience. And, yet, they are still there, practicing medicine. Brazil has been blessed with many dedicated doctors for whom their profession is a calling. Those are the doctors who have attended me. Dr. Araujo, whom I do not know, is a shining representative his profession in this country.

How are doctors reacting to President Rousseff’s proposal? Not well would be an understatement. Here in Juiz de Fora, SUS’s doctors will be joining their colleagues on July 3 in a twenty-four hour strike across the country to protest what many see as a slap in their face. (Emergencies will be treated. Optional procedures will not be performed.)  Dilma spoke of bringing in “médicos de qualidade”, which can be translated as either “quality doctors” or "qualified doctors”. Either way, those here are both – and SUS’s doctors are outraged. They are asking the same thing the rest of us are: where are these imported doctors going to work if our infrastructure is inadequate? What they want are investments to improve the hospitals and clinics, to provide adequate equipment and to maintain that equipment once they get it, money for medications that patients need, etcetera, ad infinitum. For them, importing doctors can wait. Without structural improvements, bringing more in will not make much of a difference.

In the meantime, construction on pharaonic and overpriced facilities for both the upcoming World Cup and Olympics is continuing – and we are still in the streets.

Dr. Alex Araujo's clinic in rural Minas Gerais.