HAVANA -- Free universal healthcare has long been the crowning achievement of this socialist state, but the system is now under fire from Cubans who complain that quality and access are suffering as they lose tens of thousands of medical workers to Venezuela in exchange for cheap oil, which this impoverished country desperately needs.
The close friendship between Cuban leader Fidel Castro and Venezuelan President Hugo Chavez has netted Venezuela a loan of 20,000 Cuban health workers -- including 14,000 doctors, according to the Venezuelan government -- who work in poor barrios and rural outposts for stipends seven times higher on average than their salaries at home. Castro has vowed to send Chavez as many as 10,000 additional medical workers by year's end.
In return for farming out more than one-fifth of its doctors to the petroleum-rich state, Cuba is permitted to import 90,000 barrels of oil a day from Venezuela under preferential terms. The arrangement gives Cuba's struggling economy, crippled by the US embargo in place since 1963, the biggest boost since the country lost Soviet subsidies in the early 1990s.
The Cuban doctors program is wildly popular among Venezuela's poor. But Cubans have begun to object that the exodus of their healthcare workers is taking a toll on medical care for Cubans. Most people interviewed would speak only on condition that they not be identified or asked that just their first names be used, for fear of reprisals.
A 45-year-old nurse in Camagüey province said she has worked without a doctor in her primary-care clinic for more than two years since the physician was transferred to another clinic to replace a doctor sent to Venezuela.
''My patients complain every day. They want me to act as a doctor, but I can't," she said helplessly. ''The level of attention isn't the same as before. It's not fair . . . to take from us to give to our neighbors. People are now saying, 'I've got to get a ticket to Venezuela to get healthcare!' "
Cuban doctors and nurses have long worked overseas in humanitarian missions, and their small country has made significant contributions to reducing infant mortality rates and serving disaster victims worldwide. With one of the best doctor-patient ratios in the world, Cuba could afford to loan more than 52,000 medical workers over the last four decades to 95 needy countries, including Algeria, Equatorial Guinea, and Haiti, according to official figures.
But over the last 2 1/2 years, as Castro and Chavez's cooperation has blossomed, the Cuban assistance program has substantially increased the number of medical workers overseas, with the overwhelming majority in Venezuela.
Aware of early grumblings about the exodus, Castro acknowledged in a September 2003 speech that ''it could very possibly be true that in the midst of so much movement there is no doctor in a certain place for a short time. These situations must be immediately resolved."
But rather than being speedily rectified, the situation has gotten worse, ordinary Cubans complain, with the flight of family doctors who handle primary care, a shortage of specialists, and a longer wait for eye surgery, physical therapy, and dentistry. Senior medical workers counter that many doctors were underutilized before, and that the departure of many to Venezuela has spurred a reorganization to improve efficiency at home.
The Ministry of Public Health and the Cuban press center did not respond to repeated requests over a three-week period for interviews and data for this story.
With 66,567 doctors, Cuba boasts a ratio of 1 doctor per 170 citizens, compared with 1 doctor per 188 residents in the United States, according to the World Health Organization. The emphasis on preventive, personalized care has yielded life expectancy rates almost identical to those in the United States, and infant mortality rates even lower than its northern neighbor's, WHO data show.
Advocates of the Cuban system point out that all Cubans are entitled to free healthcare and medicine, while more than 44 million American residents -- nearly one of six people -- have no health insurance.
The much-praised system has suffered setbacks, however, since the cutoff of Soviet aid some 15 years ago, with hospitals and clinics in need of renovation and equipment, pharmaceutical costs soaring, and patients complaining that they must bring their own bedclothes, sheets, food, and fans to hospitals.
But complaints about a lack of medical personnel are new, dating to the cooperation with Venezuela that some observers disparagingly call the ''oil-for-doctors program."
Castro recently raised medical workers' salaries so that a doctor with two specialties earns the equivalent of $23 a month, according to Granma, the communist party newspaper. The pay, which doesn't stretch to buy shampoo and other essentials, is one reason health workers are attracted by the extra $186 monthly stipend on average they earn in Venezuela.
Josefina Jimenez, 61, a retired Havana teacher whose son was recently hospitalized, complained that ''there are too many students doing the job of doctors, because so many physicians are in Venezuela."
Maria, a Havana dentist, said her clinic now has six instead of 16 dentists, a reduction that has ''affected quality." Danilo, 29, a Havana hospital nurse, said his overnight rounds have increased to nine from six times a month because of colleagues going to Venezuela.
In a July 26 speech, Castro dedicated a long passage to improvements to healthcare, including renovations at 50 hospitals and repairs to nearly a third of 444 health centers known as polyclinics. Castro said nearly all polyclinics now have electrocardiographs and ultrasound. ''I know how much a heart bypass costs in the US. . . . I dream that one day Americans will come to Cuba to receive treatment," he said, to approving applause.
But when he boasted that ''100,000 Venezuelan brothers and sisters" will fly to Cuba for eye treatment this year, a number of Cubans watching at home groaned at what they perceive as favoritism toward outsiders.
''It's all the Venezuelans who need cataracts surgery first, and then the Cubans if there's any time left," sniffed Georgina, 60, a retired Havana clerk.
Carlos, a 37-year-old engineer with a chronic ear problem, used to get house calls. He resents waiting 20 days for an appointment because his specialist is in Venezuela. ''Now when I need hearing tests, I see technicians who haven't even graduated yet," he muttered.
Many medical workers interviewed dismissed the criticisms as the gripes of a spoiled population unaccustomed to waiting.
''Before, there was a family doctor for every block or two of this city. Now you may have to walk six blocks -- so what?" scoffed Migdalia, a 57-year-old nurse at a Havana polyclinic. ''It's still free and the quality is the same, you just have to make an appointment nowadays or wait. . . . Cubans can even get plastic surgery -- a free boob job," she exclaimed, ''so what are they complaining about?"
Matilde, 56, a senior doctor in Camagüey, explained that ''before, we had a doctor in every factory, every school, every preschool. They were frankly underutilized. We've eliminated a lot of doctors at midlevel administrative desk jobs, and it's probably a leaner, more efficient system now."
But ordinary Cubans, accustomed to waiting interminably for nearly everything -- from transport to rations to salary increases -- retort that medical care was the one thing they never had to wait for.
Health workers acknowledged that doctor-patient relationships may suffer in the short run but said the situation is temporary, while Venezuela trains its own personnel, 27,000 of whom will begin free medical school this fall in exchange for a commitment to serve poor areas. Venezuela has 1 doctor per 542 residents, according to the WHO.
Meanwhile, medical training in Cuba has been trimmed by two years, from six years of study and a minimum four years of residency, a change that will bring more doctors into the system faster. Medical school enrollment and graduation rates are up from last year, according to official figures.
Matilde, a veteran of three overseas missions, added that Cubans shouldn't forget the exchange with Venezuela is not a one-way street; ''Because of the US embargo, we need trade and oil from Venezuela. Cuba is benefiting too."