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AVANA He knew as a child that he wanted to be a doctor, like his father. He went to medical school, became a general surgeon and ultimately a heart specialist. He practiced at Cubas premier cardiovascular hospital, performed heart transplants, and published articles in medical journals.

For this, Roberto Mejides earned a typical doctors salary: about $40 a month.

It wasnt nearly enough, even with the free housing and health care available to Cubans, to support his extended family. So in 2014, Mejides left them behind, moving to Ecuador to earn up to $8,000 a month working at two clinics and performing surgeries.

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Its a common story here, where waiters, cabdrivers, and tour guides can make 10 to 20 times the government wages of doctors and nurses thanks to tips from tourists.

Doctors are like slaves for our society, said Sandra, an art student and photographers assistant who makes more than her mother, a physician. Its not fair to study for so many years and be so underpaid.

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Cuba is proud of its government-run health care system and its skilled doctors. But even with a raise two years ago, the highest paid doctors make $67 a month, while nurses top out at $40. That leaves many feeling demoralized and searching for ways to improve their lives.

Some enter the private economy by renting rooms to tourists, driving cabs, or treating private patients, quasi-legally, on the side. Thousands of others accept two-year government assignments to work as doctors abroad, collecting higher salaries for themselves and earning billions for the state, which helps keep the stagnant economy afloat. In fact, health workers are Cubas largest source of foreign exchange.

A few doctors, like Mejides, arrange foreign employment on their own, putting at risk their future ability to return to a government job in the health system back home.

Its hard to migrate and be alone, Mejides said in Spanish, during a video phone call from Ecuador toa reporter visiting Havana in October. Its stressful. I am in the wrong place. I should be with my family in my country, working and being rewarded properly.

Still, with his Ecuador earnings, he was able to buy his wife, two daughters, and two stepdaughters a $23,000 apartment in Havana, and he sends them $300 to $500 a month.

While doctors back in Cuba grumble about their low pay, they usually find ways to make do.

Sandras mother, Nadia, a genetics researcher, earns about as much as she pays a cleaning woman to maintain her three-bedroom Havana apartment. Whenever she can, she rents one of those rooms to tourists for $40 a night, making more in two nights than she does from her monthly earnings as a doctor. She asked that her full name not be used to avoid any problems with the government.

The rental income allows Nadia to have a modestly comfortable life and to be able to buy fruits and vegetables at farmers markets. But a restaurant meal is a rare treat, and traveling abroad is impossible.

Still, she loves her work and the intellectual challenge of her research into genetic diseases. She said many Cuban doctors are committed and provide excellent service, in part because of the ways they have learned to overcome shortages of equipment and technology.

We dont have all the electronic tools, so we have to learn to do things other ways, to diagnose just by external examination, she said, over a dinner of fish and rum at her apartment.

Shed like to earn more money, of course, and she understands why so many doctors, including many she knows, have chosen to leave Cuba.

Im not ambitious for money, she said. I get rent from visitors, and I get to live in Cuba. I have a nice house, and Im happy with what I have. But Im not a millionaire.

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Cecilia, a 60-year-old former nurse who also asked that her full name not be used, spent 25 years working in government hospitals and clinics. To adapt to the shortages, she learned to make inventos medicos medical inventions using a chair or bench to raise the back of a patients bed, for example, or cutting the tip off an intravenous line to fashion an oxygen feed to a patients nose.

But she became disillusioned by the chronic shortages and the stress she saw in both her patients and colleagues.

The material scarcity is so overwhelming that it keeps people from dedicating all the passion, love, and brain power that they should to their patients in need, she said, sitting in a rocking chair in her third-floor Havana apartment. I was the one who had to face the patients and tell them we dont have the drug that you need. It was very common. And I didnt want to do that any more.

Doctors and nurses have the best intentions, but they face so many obstacles, there are so many things on their mind, she added. The doctor might be treating a patient but they are actually thinking: When I get home, at God knows what time, what am I going to feed my kid?

She quit nursing in the early 2000s and later began to pursue her passion, doing hands-on alternative medicine that combines techniques of massage, kinesiology, magnetic therapy, and so-called floral therapy, which uses extracts of flowers and herbs as healing agents.

Her work with private clients, who come to her apartment, is permitted under a license for massage, the only form of healing work included on a list of government-approved private services and businesses. Working three days a week, she earns almost $120 a month if all my appointments show up, she said. I use to make that in six months working at the hospital.

In the years after Fidel Castro seized power in 1959, Cuba invested heavily in education and science, training tens of thousands of doctors, nurses, and scientists. As a result, Cuba, a country of 11.2 million people, today has 90,000 doctors, the most per capita in the world.

About 25,000 of these doctors, along with 30,000 Cuban nurses and other health professionals, are working in 67 countries around the world. They earn about $8.2 billion in revenue for the government, according to a recent article in Granma, the official paper of the Cuban Communist Party.

The bulk of the doctors, about 20,000, are in Brazil and Venezuela. Over the last three years they provided treatment to 60 million Brazilians, mostly the rural poor, said Cristin Morales Fuhrimann, the Pan American Health Organizations representative in Havana.

Cuba receives about $5,000 a month per doctor from Brazil, pays each doctor about $1,200, and banks the rest, said John Kirk, a professor of Latin American studies at Dalhousie University in Halifax, Canada, who has researched Cubas program of medical missions. Most of the doctors shares are deposited in their Cuban bank accounts, requiring them to return home to collect it.

Cuba has too many doctors, so their main source of hard currency is to rent out medical services, Kirk said.

Once close allies of Havana, Brazil and Venezuela have been engulfed in political and economic crises that will cause them to reduce their use of Cuban doctors in the coming years.

That may lead Cuba to redeploy some doctors to other parts of the world, including the Middle East. In Qatar, an oil-rich emirate about as far from Cuba geographically and culturally as any place in the world, the so-called Cuban Hospital is fully staffed by 400 Cuban doctors, nurses, and technicians.

Cubas dispatch of doctors not only generates revenue, it is also an exercise in soft power that allows the country to spread its influence around the globe.

Its a major contribution to the health of the world, said Morales. They made a big difference in fighting Ebola in Africa, in the aftermath of Hurricane Matthew in Haiti.

Some Cuban doctors working overseas have defected to the United States, aided by a policy launched during the administration of George W. Bush that permitted Cuban medical personnel to go to the US with their spouses and children. In its last weeks in office, the Obama administration announced it was ending the program.

Since the Cuban Medical Professional Parole Program began in 2006, more than 9,000 medical professionals and their family members were approved for admission to the US. In the past four years, the number of entrants spiked, reaching almost 2,000 for the fiscal year that ended Sept. 30.

The Cuban government and the Pan American Health Organization protested the policy as a form of poaching that undermined Cubas health system and impeded newfound cooperation between the US and Cuba. In a statement, Obama acknowledged that the program risks harming the Cuban people.

Cuban doctors are in demand internationally because they come cheap, are well-trained, and work in a public health system that is highly organized and well-run. In Cuba, primary care clinics are available in every neighborhood. Specialists in cancer, immunology, genetic medicine, and cardiovascular disease staff the hospitals. Life expectancy rates, which two generations ago were at Third World levels, are today roughly equal to those in the United States.

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But the absence of so many doctors also provokes complaints from patients, who say it keeps them from getting the best care. They also grouse that they have to bring their own food and bedsheets, wait for appointments or medications and provide gifts to doctors to ensure good treatment.

When the 61-year-old father of Concepcion, a young Cuban professional, was diagnosed with prostate cancer last summer, she used personal connections to enable her father to see a specialist promptly.

Concepcion, who asked that her full name not be used to avoid reprisals or damage to her professional standing, also provided daily gifts of food, cosmetics, and sometimes cash to doctors, nurses, and technicians while her father was hospitalized for a month in Holguin, a city in eastern Cuba.

Doctors are used to receiving gifts, she said. You give the gift and the attention starts getting better. If you stop and the attention goes down, you go back to handing out gifts. You feel sorry for the doctors because they work really hard under bad conditions and you always feel like theyre not being rewarded.

She estimated she spent about $500 on gifts and food, an amount she said would have doubled had he been hospitalized in pricier Havana.

Jose dos Santos, a Cuban journalist who needs regular treatment for his diabetes, said the care he receives is excellent. Bringing gifts to doctors has become a habit because we know that the job doctors do needs to be better rewarded, he said. We dont produce oil, he added, but we produce talent, and it makes sense that that talent is acknowledged and rewarded.

In December, Roberto Mejides moved again, this time to Merida, Mexico, where he plans to work for the next four years. His income will be roughly the same as in Ecuador, but now hes just 90 minutes by air from Havana. He hopes to bring his family to join him in the coming months,

My hopes have always been the same, to work honestly and to provide my family with an adequate life, he said. Someday, he added, he wants to return to Cuba: Its my country, my homeland.

Rob Waters can be reached at robwaters@pacbell.net Follow Rob on Twitter @robwaters001

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