Cuban medical internationalism

A Cuban Doctor in Guinea-Bissau in 1974.

The programme was initiated in 1963 as part of Cuba's foreign policy of supporting anti-colonial struggles. It began when Cuba sent a small medical brigade to Algeria, which suffered from the mass withdrawal of French medical personnel during the independence war; some wounded soldiers and war orphans were also transported back to Cuba for treatment.[6][7] Cuba did this at a time when, following the Cuban revolution, "half of the country’s 6,000 doctors fled".[2] Between 1966 and 1974, Cuban doctors worked alongside Cuban artillery in Guinea-Bissau during its independence war against Portugal.[2] Cuba's largest foreign campaign was in Angola: within two years of the campaign, by 1977, "only one Angolan province out of sixteen was without Cuban health technicians."[8] After 1979, Cuba developed a strong relationship with Nicaragua.[9]

However, alongside internationalism driven by foreign policy objectives, humanitarian objectives also played a role, with medical teams despatched to countries governed by ideological foes. For example, in 1960, 1972 and 1990 it dispatched emergency assistance teams to Chile and Nicaragua, and Iran following earthquakes.[2] Similarly, Venezuela's Mission Barrio Adentro programme grew out of the emergency assistance provided by Cuban doctors in the wake of the December 1999 mudslides in Vargas state, which killed 20,000 people.[10]

Cuban medical missions were sent to Honduras, Guatemala and Haiti following 1998's Hurricane Mitch and Hurricane Georges, and remained there semi-permanently.[6] This has been part of a dramatic expansion of Cuba's international cooperation in health since 1998.[11] The number of Cuban doctors working abroad jumped from about 5000 in 2003 to more than 25,000 in 2005.[11]

In Honduras the medical personnel had a substantial impact: "In the areas they served, infant mortality rates were reduced from 30.8 to 10.1 per 1,000 live births and maternal mortality rates from 48.1 to 22.4 per 1,000 live births between 1998 and 2003."[2] However, as one academic paper notes, "The idea of a nation saving lives and improving the human condition is alien to traditional statecraft and is therefore discounted as a rationale for the Cuban approach."[2] In 2004 the 1700 medical personnel in Guatemala received the Order of the Quetzal, the country's highest state honour.[2] A 2005 attempt by Honduras to expel the Cuban mission on the basis that it was threatening Honduran jobs was successfully resisted by trade unions and community organisations.[6]

Following the 2004 Asian tsunami, Cuba sent medical assistance to Banda Aceh and Sri Lanka.[5] In response to Hurricane Katrina, Cuba prepared to send 1500 doctors to the New Orleans; the offer was refused. Several months later the mission was dispatched to Pakistan following the 2005 Kashmir earthquake there. Ultimately Cuba sent "more than 2,500 disaster response experts, surgeons, family doctors, and other health personnel", who stayed through the winter for more than 6 months.[5][12] Cuba is helping with the medical crisis in Haiti due to the 2010 Haiti earthquake.[13] All 152 Cuban medical and educational personnel in the Haitian capital Port-au-Prince at the time of the earthquake were reported to be safe, with two suffering minor injuries.[14] In 2014, Cuba sent 103 nurses and 62 doctors to help fight the Ebola virus epidemic in West Africa, the biggest contribution of health care staff by any single country.[15]

Cuba's largest and most extensive medical aid effort is with Venezuela. The program grew out of the emergency assistance provided by Cuban doctors in the wake of the December 1999 mudslides in Vargas state, which killed 20,000 people. Under this bilateral effort, also known as the "oil for doctors" program, Cuba provides Venezuela with 31,000 Cuban doctors and dentists and provides training for 40,000 Venezuelan medical personnel.[16] In exchange, Venezuela provides Cuba with 100,000 barrels of oil per day. Based on February 2010 prices, the oil is worth $7.5 million per day, or nearly $3 billion per year.[4]

Cuba has also sent notable missions to Bolivia (particularly since the 2005 election of Evo Morales) and South Africa, the latter in particular after a post-apartheid brain drain of white doctors.[17] Since 1995, a co-operation agreement with South Africa has seen hundreds of Cuban doctors practice in South Africa, while South Africa sends medical students to Cuba to study.[18] In 2012, the two governments signed another deal, increasing numbers on both sides. South African can now send 1 000 students to Cuba for training which, South Africa believes, will help train the doctors it so desperately needs for the implementation of its National Health Insurance Scheme.[19] After the 1999 violence in East Timor, the country of a million people was left with only 35 physicians and 75% of its population displaced. The number later increased to 79 physicians by 2004, and Cuba sent an additional 182 physicians and technicians.[20]

"From 1963 to 2004, Cuba was involved in the creation of nine medical faculties in Yemen, Guyana, Ethiopia, Guinea-Bissau, Uganda, Ghana, Gambia, Equatorial Guinea, and Haiti."[5]

In the 2000s, Cuba began establishing or strengthening relations with Pacific Island countries, and providing medical aid to those countries. Cuba's medical aid to Pacific countries has been two-pronged, consisting in sending doctors to Oceania, and in providing scholarships for Pacific students to study medicine in Cuba at Cuba's expense.

There are currently sixteen doctors providing specialised medical care in Kiribati, with sixteen more scheduled to join them.[21] Cubans have also offered training to I-Kiribati doctors.[22] Cuban doctors have reportedly provided a dramatic improvement to the field of medical care in Kiribati, reducing the child mortality rate in that country by 80%,[23] and winning the proverbial hearts and minds in the Pacific. In response, the Solomon Islands began recruiting Cuban doctors in July 2007, while Papua New Guinea and Fiji considered following suit.[23]

In 2008, Cuba was due to send doctors to the Solomon Islands, Vanuatu, Tuvalu, Nauru and Papua New Guinea,[1] while seventeen medical students from Vanuatu would study in Cuba.[24] It was reported that it might also provide training for Fiji doctors.[25]

As of September 2008, fifteen Cuban doctors were serving in Kiribati, sixty-four Pacific students were studying medicine in Cuba, and Cuban authorities were offering "up to 400 scholarships to young people of that region".[26] Among those sixty-four students were twenty-five Solomon Islanders, twenty I-Kiribati, two Nauruans and seventeen ni-Vanuatu.[27] Pacific Islanders have been studying in Cuba since 2006.[28]

In June 2009, Prensa Latina reported that Cuban doctors had "inaugurated a series of new health services in Tuvalu". One Cuban doctor had been serving in Tuvalu since October 2008, and two more since February 2009. They had reportedly "attended 3,496 patients, and saved 53 lives", having "opened ultrasound and abortion services, as well as specialized consultations on hypertension, diabetes, and chronic diseases in children". They had visited all the country's islands, and were training local staff in "primary health care, and how to deal with seriously ill patients, among other subjects".[29]

Missions abroad are intended to provide services at low cost to the host country. "Patients are not charged for services, and the recipient countries are expected to cover only the cost of collective housing, air fare, and limited food and supplies not exceeding $200 a month. While Cuban doctors are abroad, they continue to receive their salaries as well as a stipend in foreign currency."[2] In 2008, the pay for Cuban doctors abroad was $183 per month, whereas the pay for doctors working domestically was $23 per month.[17] A new term - "disaster tourism" - has arisen in response to a growing number of large-scale natural disasters. This phrase refers to individuals, governments and organizations who travel to a disaster area with the primary goal of having an "experience" rather than providing meaningful aid. Such aid is often short-lived, and may even get in the way of more serious rescue efforts. Cuban medical internationalism represents a polar opposite to this disaster tourism mentality, with a focus on large-scale, sustained aid targeting the most marginalized and under-served populations across the globe.[30]

Although humanitarian principles figure, ideological factors were prominent in Cuba's "doctor diplomacy", particularly during the Cold War. Subsequently, its continuation has been seen as a vital means to promote Cuba's image abroad and prevent international isolation. For Cuba's re-establishment of diplomatic relations with Honduras in 2002, Cuba's health missions in that country were "undoubtedly a deciding factor";[2] Guatemala reestablished diplomatic relations with Cuba in 1998.[5]

At the 2009 5th Summit of the Americas, U.S. President Barack Obama commented that at the summit he had heard much about the impact of Cuban "soft diplomacy" in the form of its medical internationalism. He said this might be a reminder to the United States that limiting its interactions with Latin American countries to military and drug interdiction might be limiting its influence.[31]

It has also been suggested that Cuban medical internationalism promotes exports of Cuban medical technology, and may be a source of hard currency (although the targeting of poor countries reduces the hard currency potential of missions abroad).[2] In 2006 Cuba's earnings from medical services (including export of doctors) amounted to US$2,312m – 28% of total export receipts and net capital payments. This exceeded earnings from both nickel and cobalt exports and from tourism.[17] These earnings are achieved despite the fact that a substantial part of Cuba's medical internationalism since 1998 has been organised within the framework of the "Integrated Health Program" (Programa Integral de Salud, PIS); this cooperation program is free for the receiving country.[5] Cuba's co-operation with Venezuela provides Cuba with cheap oil in exchange for its medical support to Mission Barrio Adentro.[5] Bloomberg reported in March 2014 that Cuban state-controlled media forecasted revenue of $8.2 million that year from the program.[32]

It has also been argued that the programme has, particularly in the 1980s and 1990s, "perform[ed] a critical function in consolidating socialist consciousness" within Cuba.[33]

Although Cuba's large-scale medical training programmes and high doctor-patient ratios give it much latitude, the expansion of doctor diplomacy since 2004, particularly with the Barrio Adentro programme, has been dramatic: the number of Cuban doctors working abroad jumped from about 5000 in 2003 to more than 25,000 in 2005.[11] This has had some impact on the domestic health system, for example with increased waiting times, particularly with regard to family doctors.[17] The number of patients per doctor rose from 139 to 179.[20] In March 2008 Cuba announced a reorganisation of its domestic family doctor programme for greater efficiency.[17]

In 2000, two Cuban doctors working in Zimbabwe attempted to defect to Canada. They were prevented from doing so by two Zimbabwean soldiers, who handed them over to Cuban officials.[34] United Nations officials said Zimbabwe appeared to have violated national and international laws.

In August 2006 the United States under George W. Bush created the Cuban Medical Professional Parole program,[35] specifically targeting Cuban medical personnel and encouraging them to defect when they are working in a country outside of Cuba.[6] Of an estimated 40,000 eligible medical personnel, over 1000 had entered the United States under the program by October 2007, according to the chief of staff for U.S. Rep. Lincoln Diaz-Balart.[36] The promised fast-track visa is not always forthcoming, with at least one applicant waiting a year for his visa; although according to Dr. Julio Cesar Alfonso of the Cuban dissident organization "Outside the Barrio," the U.S. government has rejected only a handful of the hundreds of applications for visas.[37] On 12 January 2017, President Obama announced the end of the program, saying that both Cuba and the US work to "combat diseases that endanger the health and lives of our people. By providing preferential treatment to Cuban medical personnel, the medical parole program contradicts those efforts, and risks harming the Cuban people."[38]

According to a 2007 paper published in The Lancet medical journal, "growing numbers of Cuban doctors sent overseas to work are defecting to the USA", some via Colombia, where they have sought temporary asylum.[39] In February 2007, at least 38 doctors were requesting asylum in the U.S. embassy in Bogotá after asylum was denied by the Colombian government.[40] Cuban doctors working abroad are reported to be monitored by "minders" and subject to curfew.[39]

According to Luis Zuñiga, director of human rights for the Cuban American National Foundation, Cuban doctors are "slave workers" who labor for meager wages while bolstering Cuba's image as a donor nation and "the Cuban government exports these doctors as merchandise".[34]