Cuban doctors offer needed help to such poor countries as Guatemala, but their presence is a source of controversy at home and in the Americas.

BY JILL REPLOGLE
Special to The Miami Herald

USPANTAN, Guatemala - At the hospital in this central Guatemala mountain town, Cuban doctors outnumber their local colleagues two to one. And all the five specialists are Cubans, including the surgeon and anesthesiologist.

Eight other Cuban doctors live and work in remote health posts in the region, sometimes trudging up to six hours on foot to vaccinate children and attend to emergencies.

''It's a beautiful, unique experience,'' said María Josefa Herrera, a Cuban general practitioner who works in Uspantán. ``Often the patients have never been treated by a medical professional.''

Herrera is one of the thousands of Cuban medical personnel sent abroad by Cuban leader Fidel Castro in a campaign to alleviate health crises, support his political allies and earn badly needed hard currency -- a campaign that also has angered some Cubans on the communist-ruled island.

Recent media reports from Havana have noted that Cubans are increasingly resenting the absence of physicians once provided free of charge by a totally government-run system whose strength was in a massive network of neighborhood doctors, and not in its hospitals or technology.

One recent U.N. mission to Cuba found a clinic in the eastern city of Santiago where 60 of the 140 staff doctors were abroad, according to the Interamerican Dialogue, a think tank in Washington. And it's not just a problem for Cubans.

LAWSUIT, COMPLAINTS

In Venezuela, the doctors' association sued the President Hugo Chávez's government for using doctors unlicensed to practice in that country. The program continued despite a court ruling backing the association. And in Honduras, the Professional Association of Honduran Doctors has complained over the presence of Cuban healthcare workers there at a time when 1,500 recent Honduran medical graduates are out of work.

Cuba touts its medical missions as a show of solidarity with the world's needy that it can well afford, with one of the highest doctor-patient ratios in the world -- one doctor for every 165 residents, according to the World Health Organization.

But there are more palpable benefits for the island. Cuban medical personnel sent abroad earn hard currency for their perennially cash-strapped government, and the estimated 20,000-22,000 deployed in Venezuela are being paid in part with cheap oil.

In Guatemala, the Cuban medical deployment also has its ups and downs.

For its part, the Guatemalan government has gained 285 physicians and 128 other medical personnel at very low costs, with government public health officials saying the Cubans earn about $400 per month -- less than half a typical Guatemalan public sector doctor's salary. Last October, Cuba sent 600 extra medical personnel to Guatemala after Hurricane Stan, but they have since returned home.

Yet that $400 is also about 16 times the average salary of a doctor in Cuba, so the Cubans here have been using their comparatively huge salaries to buy refrigerators, stereos and other items that they couldn't afford in Cuba. They take the goods home when they finish their work here.

SALARY DISTRIBUTION

Guatemalan officials say the full $400 goes to the Cubans here, who have to pay for their own housing, food and local transportation. No part goes to the Havana government, they said, although in many other countries the host government pays the Cuban government, which then passes part of the money to the medical personnel. It's not clear why the Guatemalan arrangement is different.

And for that kind of money, the Cubans are willing to toil under harsh conditions in remote areas where local doctors are not available or don't want to work. Almost three-quarters of Guatemala's 12,000 registered doctors work in the capital and surrounding suburbs, and about one-third of the country's municipalities don't have a single resident doctor, according to the Guatemalan Association of Physicians and Surgeons.

``It's difficult finding Guatemalan doctors to work in the most isolated areas,`` said Alvar Pérez, director of Guatemala's rural health extension program.

Some experts worry, however, that the public health system has become too dependent on the Cuban medical personnel.

''The Cubans came to fill a medical need,'' said Juan Carlos Verdugo of the National Health Platform, a nongovernment organization that focuses on public health issues. ``But this can't be a permanent solution . . . they could leave any day.''

To gradually replace the island's doctors, the Cuban government has been offering free medical school to low-income students from Guatemala and other countries. More than 12,000 students from 83 countries are studying at the Latin American Medical School in Havana and Castro has predicted that it will graduate 100,000 in the next 10 years.

The school's first graduation last August included 187 Guatemalans.

In exchange for free tuition, those students promised to work for the Guatemalan public health service for up to 6 ½ years after graduation. The government also requires foreign-educated doctors to work for one year for free in rural health posts and hospitals.

But many of the new graduates have said they're not willing to work for a Cuban's salary.

''No one's going to work in the mountains for a salary of $400,'' said Carlos Flores, one of the new doctors.