GOOD CAUSE: Cuba's Health Minister Roberto Morales Ojeda, centre, and SA's Health Minister Aaron Motsoaledi, right, have agreed to resume the recruitment of doctors from Cuba to work in SA hospitals.

FOURTEEN years ago, Kholekile Shasha joined SA's nascent doctor training programme in Cuba, unaware of how controversial the state-sponsored initiative would turn out to be.

He came from a poor family, and had finished high school in the Eastern Cape with exam results just shy of the grades needed to study medicine in SA. He leaped at the chance of a free education in Cuba.

"I was disadvantaged in terms of colour, and access to education and finance," he says.

The opportunity afforded him by the SA-Cuba health co-operation agreement launched in 1995 by then health minister Nkosazana Dlamini-Zuma has left him the master of seven languages, and he is well on his way to becoming a specialist.

"I speak English, Afrikaans, Spanish, Xhosa, Zulu, Tswana and Pedi, and am currently in the Eastern Cape doing a surgical training programme and studying cancer of the oesophagus."

While no one doubts the calibre of the South African doctors who eventually qualify through the Cuban medical schools, the training is expensive and time-consuming. Many observers feel the resources could be better spent training doctors in SA.

"Quite frankly, this is not the answer. I would rather we train healthcare professionals locally," says Prof Ahmed Wadee, dean of medicine at the University of the Witwatersrand (Wits).

Critics of the Cuban-training programme cite a host of problems, ranging from language difficulties to the fact that the typical diseases afflicting Cubans are worlds apart from those affecting South Africans.

Medical students in Cuba are confronted with chronic diseases like asthma and diabetes, and are unlikely to encounter critically ill patients with infectious diseases like HIV and tuberculosis, says Prof Marietjie de Villiers from the University of Stellenbosch.

"It is a completely different clinical environment. They observe more in Cuba than they do here - they have never done deliveries," she says.

The students who go to Cuba spend a year learning Spanish, followed by five years of medical training. They then enrol at a South African medical school, where they must pass final year exams in order to be registered with the Health Professions Council of SA, a requirement for practicing medicine.

Dr Shasha concedes he and his colleagues struggled to adjust when they joined medical schools in SA. "I went to the University of Pretoria. There were five of us, all black, surrounded by 30 white students, 80% of them speaking Afrikaans. I didn't pass (the first time)," he says.

Cuban-trained medical students have to relearn complex terminology in English, figure out how to use different medical equipment, and get more hands-on experience. Many students fail, some repeatedly.

Part of the rationale for training doctors outside SA is the fact that budget constraints mean its eight medical schools cannot produce enough doctors.

Their annual output has remained constant at about 1200 for the past decade, despite population growth and soaring numbers of patients with HIV and tuberculosis. SA's doctor to patient ratio is 5,7 per 10000 according to research published last year in the South African Medical Journal, while Cuba's doctor to patient ratio is 67,2 doctors per 10000, according to the World Health Organisation.

Health Minister Aaron Motsoaledi values Cuban training because it emphasises primary healthcare, encouraging doctors to work on preventing disease.

"There are three ways of dealing with diabetes: encourage healthy lifestyles, give injections and pills, (or) remove organs already damaged by the diabetes. In our present healthcare system, the doctor considered the most brilliant and worthwhile is the one who has specialised to remove organs. If there is a doctor who has specialised in making people not have diabetes, that one is not (regarded as clever)," says the minister.

But the unspoken rationale for the Cuban training programme is the African National Congress's loyalty and gratitude for the support former president Fidel Castro gave the organisation in exile during apartheid. That fidelity explains why SA gave Cuba a R350m "economic assistance package" earlier this month, and makes critics sceptical of the minister's claim that Cuba is giving SA a "discount" on the cost of training doctors to bring it on par with the local price tag.

The scheme does enjoy some support from the medical fraternity. Prof Khaya Mfenyana, dean of medicine at Walter Sisulu Medical School, says students in his department have had relatively little trouble slotting in.

"We teach in small groups so we can pick up problems quickly, and we have Cuban (staff) who know the terminology and can help them out. The students who come here spend six months in orientation, so they are on a par when they start sixth (final) year," he says.

"Although these guys don't get a lot of hands-on experience, they are very good at preventative medicine, and SA needs that," he says.

One of the aims of the Cuban training programme is to boost the numbers of doctors working in rural areas, which is ensured by requiring participants to work for the government for several years after they qualify.

But Wits Prof Ian Couper argues that getting doctors to work in rural areas does not need Cuba. He says research shows recruiting students from rural areas and giving them some of their training there is the best way to boost the numbers willing to work in remote areas.

"We desperately need as many doctors as we can get, but is (Cuba) the right way to get them?" he says.