Cuban doctors begin training at University of Brasilia, before being assigned to work in impoverished areas of the country. Cuban doctors are part of the "More Doctors" program to get more physicians working in underserved areas. (Eraldo Peres/AP)

Since the 1960s, Cuba has deployed an army of doctors by the tens of thousands to the world’s most inhospitable corners, from Haiti to Africa’s killing fields to the ultra-violent barrios of Venezuela.

Now, thousands of Cubans are heading to relatively affluent Brazil to shore up a decrepit health-care system that has become a national embarrassment.

Two months after mass protests against the substandard condition of public health and other services, President Dilma Rousseff’s government has signed a deal to bring 4,000 Cubans by the end of the year to serve for three years in forlorn outposts where health officials say Brazilian doctors will not work. Under the contract, Brazil will pay the island’s cash-starved government $4,200 a month per doctor, or $200 million annually.

But the government’s plan has its doubters. Among them is Aline Lais Ribeiro, 17, who on a recent day waited three hours to see the lone doctor working a 24-hour shift in a shabby clinic in this gritty Sao Paulo suburb, one of the 700 towns where Cuban doctors will be assigned. She asked why the government has not put resources into building a quality health-care system to match Brazil’s developed-world pretensions.

“The service is terrible,” Ribeiro said, adding that it would take two months to see a specialist for what she believed to be a urinary infection. “I think it’s wrong. They should bring doctors from this area.”

The arrival of the first 400 Cubans in recent days has raised hackles in Brazil’s health-care establishment and prompted uncomfortable questions about the inability of Rousseff’s center-left government to provide quality care in slums and remote Amazonian districts, where hospitals are in shambles and medical personnel are in short supply.

Critics say bringing in the Cubans is a half-baked measure designed more to buttress Rousseff ahead of next year’s presidential election on an issue on which she is vulnerable. During the demonstrations in June, when Rousseff’s approval ratings fell sharply, Brazilians told Datafolha pollsters that their greatest concern, more so than corruption, crime or failing schools, was the country’s ramshackle public health system.

“The government doesn’t organize the health system, doesn’t fund the system, and now they think that bringing the Cubans in to provide aspirin and hold a patient’s hand is medicine. It is not medicine,” said Jose Bonamigo, a doctor and treasurer of the Brazilian Medical Association, which opposes the plan.

200 patients a day

Here in Embu Guacu, at the one-story Basic Health Unit, the harried physician, Francisco de Brito Pedrão, 31, said Brazilian doctors are reluctant to work in remote areas or poor urban districts because of inadequate equipment and facilities. As he spoke, a black street dog roamed a corridor. The clinic has cracked wooden doors, walls where brick is exposed behind peeling paint and rooms outfitted with decades-old metal beds.

To make matters worse, Pedrão is the only doctor in the facility. “I spend 24 hours alone — it’s hard,” he said, listing the basic but much-needed equipment the clinic lacks. “I usually see 200 people. I’d like to have more time, but I can’t give people the attention they deserve.”

Indeed, 40 people were waiting to see Pedrão, including João Antonio de Sousa, who wondered when his 6-year-old son, suffering from a fever for two days, would get service.

“The health system is terrible not only here, but terrible all over Brazil,” Sousa said.

Riordan Roett, director of Latin American studies at Johns Hopkins University and author of “The New Brazil,” said importing the Cubans underscores the “extraordinarily bad health-care system.” But he said it also reflects the huge gaps between rich and poor that are part of life in Brazil, despite the bigger middle class that has emerged in recent years.

“What the elite do in Brazil is the same as in Argentina and elsewhere in Latin America: They support private health clinics and private schools and are reluctant to help the poor,” Roett said. Rousseff’s plan might be a good short- or medium-term solution, he said.

Concerns over pay, quality

In an interview, Brazil’s health minister, Alexandre Padilha, extolled the Cuban doctors for their know-how — 84 percent of the first 400 have at least 16 years of experience — and their ability to work in difficult conditions with people on the margins of society.

Padilha said the Cubans are being assigned to “small communities, in the poorest barrios, where 13 million Brazilians live who do not have the care of any doctor.”

Brazil has only 1.8 doctors per 1,000 people — not only fewer than in developed nations, but also a smaller ratio than in neighboring countries such as Argentina and Uruguay. That led Brazil to appeal to doctors from Spain, Portugal, Argentina and other places to come work here. Although hundreds have arrived in recent weeks, Padilha said it is far from enough.

The minister said the contract with Cuba is part of a broader strategy to improve medical infrastructure and train more Brazilian doctors.

Critics, though, have questioned the quality of the service the Cubans will provide and the legality of the contract that permits them to work in Brazil. Some also say Cuba keeps the vast majority of the money paid for its medical services, providing only a small percentage to the doctors, nurses and medical technicians who serve in 58 countries.

Brazil’s government will channel payments to the Pan American Health Organization (PAHO), a Washington-based branch of the World Health Organization, which then pays Cuban President Raúl Castro’s government. Brazil’s government and the PAHO say they do not know how much Cuba will pay its doctors. But Cuba’s vice minister for health, Marcia Cobas, said the Cubans in Brazil will receive 40 to 50 percent of the $4,200 that Brazil is paying monthly for each doctor.

That’s a fortune to Alain Garcia Caballero, a Cuban nurse who last year defected from Venezuela, where Cuba has its largest medical presence. He said he was paid less than $100 a month for working in a violent barrio.

He said many of the Cubans arriving in Brazil will think of defecting, but most will not because of fear that their families in Cuba will face reprisals. “I think all the Cuban doctors, everyone on these missions, think about it,” Garcia said from Miami, where he now lives.

He said medical personnel sent overseas go through a rigorous “ideological” preparation course in Cuba, during which they are taught to avoid talking to the media or people in their host countries about politics. To keep defections to a minimum, Garcia said, Cuban agents are deployed along with doctors.

In an interview with Brazilian radio, Rousseff said the Cubans will be treated well, receiving “housing, food, everything that we can do under the law to take doctors to areas where there are no doctors.” She stressed that the Cubans are being welcomed along with doctors from other countries who have agreed to work in remote regions.

In the clinic at Embu Guacu, Marilene Braz, 33, said the arrival of the Cubans could improve services. She accompanied her husband, who had been hurt in a motorcycle accident and had been waiting three hours to see the doctor.

“If they can do some good, they can come here,” she said. “I’m worried about the language. But I think they might be able to learn Portuguese.”

Forero reported from Bogota, Colombia.