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Cuban Medical Diplomacy: When the Left Has Got It Right

And now, with help from his friend, Hugo Chávez, who is awash in oil wealth, Fidel is threatening to provide massive amounts of medical aid to improve the health of poor Latin Americans. Rather than a fifth column promoting socialist ideology, these doctors provide a serious threat to the status quo by their example of serving the poor in areas in which no local doctor wouldwork, by making house calls a routine part of their medical practice and by being available free of charge 24/7, thus changing the nature of doctor-patient relations. As a result, they have forced the re-examination of societal values and the structure and functioning of the health systems and the medical profession within the countries to which they were sent and where they continue to practice. This is the current Cuban threat.

Over the past forty-five years, Cuba’s conduct of medical diplomacy has improved the health of the less privileged in developing countries while improving relations with their governments. By the close of 2005, Cuban medical personnel were collaborating in 68 countries across the globe. Consequently, Cuban medical aid has affected the lives of millions of people in developing countries each year. And to make this effort more sustainable, over the years, thousands of developing country medical personnel have received free education and training either in Cuba or by Cuban specialists engaged in on-the-job training courses and/or medical schools in their own countries. Today, over 10,000 developing country scholarship students are studying in Cuban medical schools. Furthermore, Cuba has not missed a single opportunity to offer and supply disaster relief assistance irrespective of whether or not Cuba had good relations with that government. This includes an offer to send over 1000 doctors as well as medical supplies to the United States in the immediate aftermath of Hurricane Katrina. Although the Bush administration chose not to accept the offer, the symbolism of this offer of help by a small, developing country that has suffered forty-five years of US hostilities, including an economic embargo, is quite important.

Symbolic Capital and Symbolic Politics: the Context for Medical Diplomacy
Because good health is necessary for personal well-being as well as societal development, the positive impact of Cuba’s medical aid to other countries has greatly improved both its bilateral relations with those countries as well as its standing and support in a number of multilateral forums. Therefore, as a consequence of its medical diplomacy Cuba has accumulated considerable symbolic capital (goodwill, prestige, influence, credit and power). The creation of symbolic capital requires an initial investment of material capital as well as time in a given project, such as the efforts mentioned above. The resulting symbolic capital may be accumulated, invested and spent just like material capital. Eventually, it can be converted into material capital, which in Cuba’s case has meant both bilateral and multilateral aid as well as trade, credit and investment. This is one of the rewards for the conduct of medical diplomacy.

From the outset of the revolution, Fidel has made the health of the individual a metaphor for the health of the body politic. Therefore, he made the achievement of developed country health indicators a national priority. Rather than compare Cuban health indicators with those of other countries at a similar level of development, he began to compare them to those of the United States. This was particularly true for the infant mortality and life expectancy rates. Both are considered to be proxy indicators for socioeconomic development because they include a number of other indicators as inputs. Among the most important are sanitation, nutrition, medical services, education, housing, employment, equitable distribution of resources, and economic growth. It is, therefore, symbolically important for Cuba to compare favorably with the US in an effort to demonstrate what Fidel sees as the moral superiority of Cuba’s social development policies.

This striving for first world health has been so important that in many of his major speeches, Fidel has dedicated considerable time to discussing his island’s health indicators. His annual July 26 speech this year, given right before his own serious illness was made known to the public, was no exception. In it, Fidel cited the latest data: Cuba’s infant mortality rate was 5.6 per 1000 live births, a figure less than that of the United States, which was 7.0 per 1000 live births according to the latest published data (NCHS 2005, data are for 2002). Life expectancy at birth in Cuba today is the same as for US citizens, 77 years. These achievements make Cuba a model and therefore make possible its medical diplomacy.

In the past thirty-five years Cuba has tripled its number of health care workers. Even more striking is the change in the ratio of doctors to population. This went from one doctor for every 1,393 people in 1970 to one doctor for every 159 people in 2005. This was part of Fidel’s 1984 family doctor plan to put a doctor on every block. Having accomplished this in both urban and rural areas, even isolated ones, Cuba is now exporting this model through its medical diplomacy initiatives.

Cuba’s accomplishments in health realms are not just in primary care or in the production of doctors. There was a simultaneous development of high tech medicine and biotechnology as well. Cuba shares its expertise through numerous international medical conferences that it holds every year and through scientific exchanges. Because research is also an important part of the operation of the health system, in the medical and public health field alone, Cuba publishes fifty-four professional journals.

As early as 1982, the US government recognized Cuba’s success in the health sphere in a report that affirmed that the Cuban health system was superior to those of other developing countries and rivaled that of many developed countries. Despite economic hardship during the 1990s after the dissolution of the Soviet Union and the subsequent loss of its preferential economic relations along with the tightening of the then three- decade-old US embargo, Cuba continuously increased its spending on domestic health as a percentage of total government spending in order to shield the most vulnerable population from the worst effects of the crisis. As a result, the initial deterioration in the population’s health status was short-lived and the health indicators quickly improved. Today, even some US analysts who oppose Fidel Castro agree that Cuba’s health system has produced impressive results despite the many material shortages that it always has faced. Some critics also recognize, albeit reluctantly that Cuban medical diplomacy is producing positive effects in the recipient countries.

Selected Examples of Cuban Medical Diplomacy
Perhaps as a portent of things to come, even during the 1970s and 1980s Cuba implemented a disproportionately larger civilian aid program (particularly medical diplomacy) than its more developed trade partners: the Soviet Union, the Eastern European countries and China. This quickly generated considerable symbolic capital for Cuba, which translated into political backing in the United Nations as well as material benefits in the case of Angola, Iraq and other countries that could afford to pay fees for professional services rendered, although the charges were considerably below market rates.

Early success with medical diplomacy and the accumulation of symbolic capital as well as the ability to convert it into material capital, led Fidel to announce in 1984 that Cuba would train 10,000 new doctors specifically to increase the volume of international medical aid. No country other than Cuba has developed doctors as an export commodity. This has paid off handsomely both for the government of Cuba and for the individual doctors involved, as they usually earn considerably more money abroad than in Cuba.

The Cuba-Venezuela-Bolivia Connection
It is, indeed, ironic that in 1959 Fidel unsuccessfully sought financial support and oil from Venezuelan president Rómulo Betancourt. It would take forty years and many economic difficulties before another Venezuelan president, Hugo Chávez, would provide the preferential trade, credit, aid and investment the Cuban economy desperately needed. This partnership is part of the Bolivarian Alternative [to the US] for the Americas (ALBA) to unite and integrate Latin America in a social justice-oriented trade and aid block under Venezuela’s lead. It also has created an opportunity to expand Cuba’s medical diplomacy reach well beyond anything previously imaginable despite Fidel’s three-decade-long obsession with making Cuba into a world medical power; an obsession which was analyzed and documented in my 1993 book, Healing the Masses: Cuban Health Politics at Home and Abroad.

By far the largest Cuban medical cooperation program ever attempted is the present one with Venezuela under Hugo Chávez. The symbolic and material payoffs for Cuba are clearly demonstrated, for example, by the oil-for-doctors trade agreements between the two countries. The accords allow for preferential pricing for Cuba’s exportation of professional services vis-à-vis a steady supply of Venezuelan oil, joint investments in strategically important sectors for both countries, and the provision of credit. In exchange, Cuba not only provides medical services to unserved and underserved communities within Venezuela (30,000 medical professionals, 600 comprehensive health clinics, 600 rehabilitation and physical therapy centers, 35 high technology diagnostic centers, 100,000 ophthalmologic surgeries, etc.), but also provides similar medical services in Bolivia on a smaller scale at Venezuela’s expense. And to contribute to the sustainability of these health programs, Cuba will train 40,000 doctors and 5,000 healthcare workers in Venezuela and provide full medical scholarships to Cuban medical schools for 10,000 Venezuelan medical and nursing students. An additional recent agreement includes the expansion of the Latin American and Caribbean region-wide ophthalmologic surgery program (Operation Miracle) to perform 600,000 eye operations over ten years.

The main medical aid programs are the provision of comprehensive health services throughout Venezuela through the Barrio Adentro programs (Barrio Adentro I and II). As of March 25, 2006, there were a total of 31,390 medical personnel (mostly doctors) providing services through Barrio Adentro I, the primary health care program. Of that number, 23,382 were Cubans and the 8008 were Venezuelan. These Cuban “medical diplomats” had conducted 171.7 million medical consultations, of which 67.9 million were carried out in the communities (schools, workplaces, and homes). They visited 24.1 million families at home, something previously unheard of on that scale and in those locales. Moreover, these personnel provided 103.1 million health educational activities as well.

During the same period, under Barrio Adentro II, which provides medical diagnostics and physical therapy and rehabilitation, 10,856 histological exams were conducted, 84.4 million clinical laboratory exams were done, 808,153 CAT scans and 47,454 nuclear magnetic resonance exams were performed, among others. The newly established Comprehensive Diagnostic Centers handled 886,609 emergency room visits and performed 7.2 million diagnostic exams; and the Comprehensive Rehabilitation Wards also established under Barrio Adentro II handled 520,401 rehabilitation consultations and applied 1.6 million rehab treatments.

The second largest medical cooperation program is with Bolivia, where in June 2006, 1,100 Cuban doctors were providing free health care, particularly in rural areas, in 188 municipalities, mainly in the departments of La Paz, Santa Cruz, Cochabamba and Chuquisaca. Cuba already has provided the National Ophthalmologic Institute in La Paz with modern equipment and specialized personnel who, along with Bolivian doctors and recent graduates from the Latin American Medical School (ELAM), have treated over 1,500 patients free of charge. New accords stipulate the opening of two additional ophthalmologic centers, one in Cochabamba and another in Santa Cruz. They each will be able to treat 50 patients a day and the La Paz center will allow doctors to attend to 100 patients a day. As a result, Bolivia will have the capacity to perform ophthalmologic operations on a minimum of 50,000 patients annually.

Cuban sources indicate that by the end of July their medical team had attended one million Bolivians free of charge (to the patient) and had performed 23,000 ophthalmologic operations. Additionally, Cuba offered 5,000 more full scholarships to educate doctors and specialists as well as other health personnel at ELAM in Havana. At present, there are some 500 young Bolivians studying at the school and another 2,000 have started the pre-med course there. The six-year medical school program is provided free for low-income students who commit to practice medicine in underserved communities in their home countries upon graduation.

During the ELAM’S first graduation last August, Venezuelan President Hugo Chávez announced that his country will establish a second Latin American Medical School, so that jointly with Cuba, the two countries will be able to provide free medical training to at least 100,000 physicians for developing countries over the next 10 years. The humanitarian benefits are enormous, but so are the symbolic ones. Moreover, the political benefits could be reaped for years to come as students trained by Cuba and Venezuela become health officials and opinion leaders in their own countries. Today, medical students whom Cuba trained as doctors in the 1970s, are now in positions of authority and increasing responsibility.

Other Western Hemisphere Examples
Cuban medical teams had worked in Guyana and Nicaragua in the 1970s, but by 2005 they were implementing their Comprehensive Health Program in Belize, Bolivia, Dominica, Guatemala, Haiti, Honduras, Nicaragua, and Paraguay. Throughout the years, Cuba also has provided free medical care in its hospitals for individuals from all over Latin America and not just for the Latin American left. Please consult the bottom of this report for a list of countries for which Cuba has provided some type of medical assistance as of December 2005.

Under Haitian President Rene Préval, Cuba began its medical cooperation with Haiti in 1998. Currently, there are approximately 400 Cuban medical professionals working in Haiti on two-year assignments in 110 of the 164 comunes across the island. The program costs the Haitian government approximately US$1.8 million annually, which averages out to cost US$375 per month for each medical professional plus room and board, transportation and exemption for airport departure taxes. Because money is fungible, it is not evident which donor is providing the funding. Although very inexpensive by international standards, this program is relatively costly for the cash-strapped Haitian government and could become even more so if it is expanded as has been discussed recently.

Jamaicans, among others, with little means have been going to Cuba for free eye surgery as part of Operation Miracle. A spokesperson for the Jamaican Health Ministry has indicated that they had received positive feedback on the surgeries that had been administered. The number of patients reported with complications amounted to fewer than three per cent of the 1,854 patients who were treated in Cuba as of 2006.

As previously mentioned, Cuba has offered disaster relief over the years to every country that has experienced an emergency. And most often the offer has been accepted. A recent (2005) example is Guyana, where Cuba sent a team of 40 medical doctors and technicians to provide disaster relief after severe flooding had been recorded in the country.

Because Cuba has been successful in developing health programs at home and has provided medical aid abroad, often under difficult circumstances, some donor countries are willing to provide financial support for Cuban medical assistance in third countries in what is called triangular cooperation. Germany has provided funding for Cuba to develop health programs in Niger and Honduras. France provided some funding to execute a health program in Haiti. Japan provided two million doses of vaccines to vaccinate 800,000 children in Haiti and US$57 million to equip a hospital in Honduras where a Cuban medical brigade works.

Multilateral agencies, such as the World Health Organization (WHO) and the Pan American Health Organization (PAHO) also finance medical services provided by Cuba for third countries. Both organizations provided funding for Cuba’s medical education initiatives. Finally, Cuba’s Comprehensive Health Program, which is being exported to various countries that receive Cuban medical assistance, is supported by 85 NGOs and through triangular cooperation with both governments and NGOs, has received US$2.97 million in support. Although some of the amounts are small, it is clear that donors find that support for Cuba’s medical diplomacy makes professional sense.

Medical Diplomacy Outside of the Western Hemisphere
Cuba dispatched very large civilian aid programs in Africa to complement its military support to Angola and the Horn of Africa in the 1970s and early 1980s. With the withdrawal of troops and the later geopolitical and economic changes of the late 1980s and the 1990s, Cuba’s program was scaled back, but remained. Having suffered a post-apartheid brain drain (white flight), South Africa began importing Cuban doctors in 1996. Already in 1998 there were 400 Cuban doctors practicing medicine in townships and rural areas. By 2004, there were about 1200 Cuban doctors working in African countries, including in Angola, Botswana, Cape Verde, Côte d’Ivoire, Equatorial Guinea, Gambia, Ghana, Guinea, Guinea-Bissau, Mozambique, Namibia, Seychelles, Zambia, Zimbabwe, and areas in the Sahara.

On the African continent, South Africa is the financier of some Cuban medical missions in third countries. This South African-Cuban alliance has been much more limited in scope than the Venezuelan-Cuban deal. Discussions on the extension of Cuban medical aid into the rest of the African continent and a trilateral agreement to deploy over 100 Cuban doctors in Mali with US$1 million in South African financing, were concluded in 2004. Rwanda was to be next in a similar agreement. Cuba also had deployed 400 medical doctors to Gambia. As of December 2005, Cuba was implementing its Comprehensive Health Program in Botswana, Burkina Faso, Burundi, Chad, Eritrea, Gabon, Gambia, Ghana, Guinea-Bissau, Guinea-Conkary, Equatorial Guinea, Mali, Namibia, Niger, Rwanda, Sierra Leone, Swaziland, and Zimbabwe.

Cuban medical teams also have worked in East Timor since 2004 to create a sustainable health system. Currently, 182 medical professionals are providing a variety of services in Cuba’s Comprehensive Health Program. At the same time, Cuba offered full medical school scholarships for 800 East Timorese students to begin work on the sustainability of their program.

Recent Cuban disaster relief medical missions are still providing assistance in post-tsunami Indonesia and post-earthquake Pakistan. Shortly after the tsunami, Cuba sent a medical team and equipment to provide disaster relief. At the time, the team was handling over 150 consultations daily in a military field hospital and a polyclinic. They also were providing some preventive as well as curative care on their visits to refugee camps. Less than a week after the devastating October 2005 earthquake in Pakistan, Cuba sent a team of highly experienced disaster relief specialists comprised of 2300 doctors, nurses and medical technicians. Part of the team worked in refugee camps and Pakistani hospitals. The rest worked in 30 field hospitals located across the earthquake-stricken zone. The team brought everything they would need to establish, equip, and run those hospitals. The cost to Cuba was not insignificant. Two of the hospitals alone cost half a million dollars each. Only recently (May 2006), Cuba sent 54 emergency electrical generators as well.

In the past Cuba has also provided aid to Armenia, Iran, Turkey, Russia, as well as to most Latin American countries that have suffered either natural or man-made disasters. This type of medical diplomacy in the affected country’s time of need has garnered considerable bilateral and multilateral symbolic capital for Cuba, particularly when the aid is sent to countries considered more developed.

In Search of Sustainability: Provision of Medical Education and Training in Cuba and Abroad
In an effort to have a more sustainable impact on the health of the aid recipient countries’ populations as well as a multiplier effect on the immediate aid given, medical education always has been an important part of Cuba’s medical diplomacy. Education and training consist of on-the-job training, seminars, courses and full medical education. As early as the 1970s, Cuban medical professors either established medical schools or taught in medical faculties in Angola, Ethiopia, Guinea-Bissau, Nicaragua, and Yemen. This has been a continuing process ever since.

Cuba has long provided total scholarships for students from other developing countries to study anywhere from secondary school (medical technicians) through post-graduate studies. From 1961 to 2001, almost 40,000 foreign scholarship students had graduated in various medical disciplines from Cuban schools. Of those, 16,472 graduated from institutions of higher education. These numbers peaked in the 1980s before the fall of the Soviet Union. Now, with an oil-for-services agreement with Venezuela, Cuba is vastly increasing its scholarship offerings.

The Latin American Medical School (ELAM) was established in 1998 specifically to train students from poor communities in Latin American and African countries. In exchange for full scholarships, these students must be willing to return to their countries and practice medicine in poor communities for at least five years. After meeting with members of the US Congressional Black Caucus a few years ago, Fidel announced a symbolically significant plan for medical diplomacy with the United States: 500 full scholarships to Cuba’s ELAM for US minority students. Half of the scholarships would be for African Americans and the other half divided between Hispanics and American Indians. So far only a few Americans have accepted the offer.

There were a total of 10,661 foreign medical students from 27 countries studying in Cuba at the ELAM during the 2005-2006 academic year. Of this total, 10,084 were enrolled in medicine, 67 in stomatology (dentistry), 134 in nursing, and 376 in health technology. This is triple the number of medical students enrolled in 2002. To train French-speaking Africans and Haitians, the Cuban Government established the Facultad Caribeña de Medicina (Caribbean Medical School) in Santiago de Cuba, where 254 Haitians and 51 Malian students were studying in 2002.

Graduates from these medical schools take the National Final Cuban Examinations (NFCE) at the end of their program and then do an internship in their home countries. After that, they must take their home country’s qualifying exam just as all other medical students must do to be licensed to practice medicine. Reports from Chile, which has one of the most highly developed health systems in Latin America and a rigorous university system and medical licensing requirements, indicate that the first seven Chilean medical students who have graduated from ELAM and returned to Chile have had their degrees validated by the University of Chile as required and have entered successfully into Chile’s public health system. This suggests that the quality of education provided at the ELAM is high. The fact that Cuban doctors who have found work in Chile on an individual basis have had their credentials validated by the University of Chile in what one Chilean official said was a complicated and demanding process, attests to the overall quality of Cuban medical education.

Medical Diplomacy Wins Friends But Also Makes a Few Enemies
Medical diplomacy primarily wins friends among the governments whose people receive the aid and the patients and students who directly and individually benefit from it. But not all are thrilled to have Cuban doctors in town. In particular, local medical associations and individual doctors have harshly criticized the Cuban presence because of their competition for jobs, their different manner of working and treating patients, and because of the perquisites they receive (principally, free room and board). In some cases, such as in Bolivia and Venezuela, these medical associations have gone on strike to protest the Cuban presence. In these and some other cases, such as in South Africa and Haiti, they have taken their complaints to the press. Despite protests (and strikes), numerous press and other reports from different countries extol the benefits to the patients, many of whom had never seen a doctor before, particularly living and working in their own neighborhood.

Not surprisingly, these medical associations sometimes seek to discredit the Cubans and use what appears to be a technical argument, the questioning of certification standards (credentials) and quality of care. Medical licensing is a standard practice in all countries, but it can be and is used by some who feel threatened by the competition of Cuban doctors willing to serve in areas that they themselves would not go, let alone work. On the other hand, standards are important and ideally, there should be a WHO or other supra-national independent accreditation agency that could establish criteria for and validate medical degrees and licenses or establish equivalences so as to eventually allow for global labor mobility. This, however, would be extremely difficult to negotiate and is unlikely to occur in the next few decades. Therefore, Health Ministries, or, in some cases, medical associations become the gatekeepers for entry into the profession. This is tricky when vested interests are in charge of the licensing or accreditation process or are politically strong enough to block it. In 2003, the Venezuela Medical Federation, which is ideologically opposed to the Chávez government and the Barrio Adentro medical program, filed a lawsuit to prohibit Cuban doctors from practicing medicine there. The court held in favor of the Medical Federation, but the Venezuelan government did not back down.

Similarly, in Bolivia, when the Colegio Médico de Bolivia and the association of unemployed doctors went out on strike to protest the presence of the Cuban doctors, President Evo Morales asserted publicly that the Cubans would stay as long as he is in office. He also exhorted the Colegio Médico to change its attitude and to “pay” with their professional services for their free medical education in public universities paid for by Bolivian taxpayers. Like in the case of Venezuela, the benefits to the host society far outweigh the costs to the local medical professions, which in these two cited cases are ideologically opposed to the government.

At the urging of the Haitian medical association, the previous government asked for a revision of the cooperation agreement to include better control by the Ministry of Health over the mix and quality of medical staff sent as well as the nature of their work in the field. However, this revision has yet to take place. Some malpractice accusations have been made against Cuban doctors in Venezuela, South Africa, Zimbabwe, and Haiti. A much-publicized case in Venezuela proved to be the fault of opposition doctors who refused to treat a patient referred to a hospital by a Cuban doctor. On the other hand, it is quite possible and, indeed, probable that there are some genuine cases that need to be addressed. This would be normal among all cohorts of practitioners and should be properly investigated and remedied.

Rewards For Medical Diplomacy
As stated at the outset of this article, Cuba’s rewards are symbolic and material capital. There is enormous prestige and influence in determining the direction of public health systems in the countries in which Cuba practices medical diplomacy. The training of future leaders in the medical field assures Cuba of on-site support in the future. More importantly, Cuba’s medical diplomacy contributes to the positive views held by other governments as translated into voting results at the United Nations on issues of particular importance to Cuba, such as an end to the US embargo of Cuba and the stressing of human rights issues. Importantly, Cuba was elected to the new UN Human Rights Council by direct, secret ballot in which all member states were elected individually and not in blocs.

In a press conference reported in the daily Última Hora, Paraguayan President Nicanor Duarte Frutos explained why his country would abstain rather than vote in favor of the US sponsored anti-Cuba resolution at the UN Human Rights Commission in Geneva, despite President Bush’s personal call in April 2004 asking for his support. The reason: a cooperation agreement with Cuba dating back more than six years, whereby Cuban doctors provide medical assistance in Paraguay and Paraguayan youths from very poor families are studying in Cuba on scholarships. At that time, there were 600 students involved in the program.

With regard to the US embargo of Cuba, the US State Department’s own data show that in the 2005 General Assembly votes, only Israel, the Marshall Islands and Palau supported the US position. This was the fourteenth consecutive time in which the US position was rejected, but to no material benefit to Cuba since the US has been going it alone for a long time now on this issue. Among Cuba’s trade and aid partners, voting coincidence with the US generally ranked only between 6 and 22 percent during 2005. The overall average coincidence for all countries was only 25%. The LAC average was 19.7%. The Asian group average was 18.7%; the African group averaged 13.5%; the Eastern European group averaged 40.4%; and the Western European and Others (Australia, New Zealand) came in at 46.7%. Cuba’s medical diplomacy should be seen as contributing to this pattern. Rather than isolating Cuba, it is the US that is becoming more isolated on this issue.

Far from being marginalized by Washington’s anti-Havana offensive, Cuba has remained an important member of the Non-Aligned Movement and once again has just hosted the summit of heads of state and government in September and has become the leader of the NAM for the next several years. Cuba previously hosted and led the NAM in 1979. Also Fidel attended the July 2006 MERCOSUR summit, which opened with the signing of a trade agreement with Cuba for mutual preferential market access. The agreement consolidates the already existing bilateral agreements on preferential tariffs that Cuba has had with each of the MERCOSUR members. Although the amount of trade between Cuba and MERCOSUR is not great, the agreement is significant for its timing: just before the release of the US-sponsored Commission for a Free Cuba’s tough report on tightening the US embargo and promoting regime change.

More importantly from an immediate standpoint are the export earnings deriving from medical diplomacy. Data on the amount paid for the various activities involved in Cuban medical diplomacy has always been difficult to establish. Rates paid for doctors have ranged from nothing where the country could not afford to pay, to some rate well below market prices. Nonetheless, rough estimates suggest that the amounts are truly significant and have surpassed earnings from tourism. The Economist Intelligence Unit estimates that the increase in non-tourism services exports between 2003 and 2005 was around US$1.2 billion for a total of US$2.4 billion, which puts non-tourism services ahead of gross tourism earnings (of US$2.3 billion) in 2005. Most of this is medical services.

Official data for export earnings from medical products (medicines and equipment) were below US$100 million in 2004, but there have been press reports citing a figure of US$300 million for such products. Cuba exports medical biotechnology products to 40 countries, but sales data were not available. Two important earnings streams not included in the export data come from the licensed manufacture of Cuban medicines in other countries and joint-venture production facilities abroad. Officials in Havana have indicated that these are significant, but no concrete data is available. Cuba has some licensing agreements, including one in the US for anti-cancer drugs, and even joint venture production facilities in China. Also, treatment facilities are being built in other countries, particularly in the field of ophthalmology, under agreement with Venezuela. The oil-for-doctors agreement is very lucrative for Cuba because of preferential pricing for Cuba’s professional services exports and because Venezuela absorbs the loss for any escalation of oil prices, a factor that has occurred to a considerable degree in recent months. Commercial trade between Venezuela and Cuba surpassed US$ 2.4 billion in 2005 and US$1.2 billon in the first trimester of 2006. Also, on the aid side between 2002 and 2006, Cuba has received some US$50 million for a range of physical development programs from the Organization of Petroleum Exporting Countries Fund. These rewards make medical diplomacy well worth the effort, not to also mention the important humanitarian benefits.

The Cuban Challenge
Taking medical diplomacy a degree further, at the recent MERCOSUR summit in Córdoba, Argentina, Fidel called for a social agenda to globalize solidarity in health and education. He offered Cuba’s experience in health and education to support that agenda. In these remarks, he laid down a gauntlet not only for MERCOSUR, but also for his adversary, the US government. It appears, however, that no one will take him up on it.

Post-Fidel Medical Diplomacy
Fidel transferred power to his slightly younger brother Raúl Castro just days before the Non-Aligned Movement meeting was convened in Havana. Indications are that although Raúl is the heir apparent, something approaching a de facto collective leadership most likely will govern Cuba in the near future. This leadership group probably will include not only Raúl, but also Ricardo Alarcón, who presides over the National Assembly of People’s Power; Carlos Lage, Vice President; and Foreign Minister Felipe Roque Pérez. None of these figures is expected to alter significantly Cuba’s practice of medical diplomacy in the near term. As long as the export of excess Cuban doctors continues to provide both material capital (e.g., oil-for-doctors) and symbolic capital (e.g., support in international forums), it is likely to be maintained. However, the scale of this program depends more on Hugo Chávez’s largesse than on Cuba’s willingness to continue it.

The temporary export of Cuban doctors also provides a safety valve for disgruntled medical professionals who earn much less at home than less skilled workers in the tourism sector. Their earning opportunities abroad are significant both within the confines of medical diplomacy and even more so, beyond it. This has led to a number of defections, allegedly around six hundred, although some say this figure is too high. This figure could grow if Cuban-American activist groups carry out their threats to assist these doctors serving in foreign lands if they defect. Should this number increase dramatically in this period of political change, the Cuban government may decide that the cost is too great to bear. In an effort to break the oil-for-doctors bond that supports the Cuban economy and create a medical brain-drain, the Bush Administration announced (on August 7) a possible change in its Cuba policy to ease immigration for Cuban doctors who participate in Cuba’s medical programs abroad. This is in sharp contrast to its tightening of policy regarding immigration of Cubans who enter the U.S. illegally. The lure of vastly increased earnings, easy access to high technology, and a much better material quality of life may lead doctors born, raised and trained at great expense in revolutionary socialist Cuba to cease helping those in need in developing countries and depart en masse. If they do, this is unlikely to break the ties that currently bind Cuba and Venezuela. But, this will raise questions about the consistency of US immigration policy. The fact that the Bush administration is trying to destroy Cuba’s medical diplomacy program indicates that the program works. Rather than attempt to destroy it, the Bush administration should emulate it.

Countries in which Cuba provides collaboration in Health by region, December 2005

The Americas
Antigua and Barbuda, Argentina, Aruba, Bahamas, Belize, Bolivia, Brazil, Colombia, Costa Rica, Dominica, Ecuador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Venezuela, Dominican Republic, St. Kitts and Nevis, St. Vincent and the Grenadines, St. Lucia, Suriname, Trinidad and Tobago

Africa
South Africa, Angola, Botswana, Burkina Faso, Burundi, Cape Verde, Congo, Djibouti, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Equatorial Guinea, Guinea-Bissau, Guinea, Lesotho, Mali, Mozambique, Namibia, Niger, Rwanda, Sao Tome and Principe, Seychelles, Sierra Leone, Swaziland, Chad, Uganda, Zimbabwe, RASD, Algeria

Asia
Qatar, Yemen, Laos, Pakistan, East Timor, Indonesia

Europe
Italy, Switzerland, Ukraine

Source: Statistical Registers of the Central Medical Cooperation Units, 2005 Statistical Yearbook of the Cuban Ministry of Public Health

Julie M. Feinsilver is the author of “Healing the Masses: Cuban Health Politics at Home and Abroad” (Berkeley: University of California Press, 1993). Dr. Feinsilver is a Senior Research Fellow at the Council on Hemispheric Affairs in Washington, DC, and an international civil servant. The views expressed herein are solely her own and do not necessarily reflect those of any institution with which she is affiliated.

And now, with help from his friend, Hugo Chávez, who is awash in oil wealth, Fidel is threatening to provide massive amounts of medical aid to improve the health of poor Latin Americans. Rather than a fifth column promoting socialist ideology, these doctors provide a serious threat to the status quo by their example of serving the poor in areas in which no local doctor wouldwork, by making house calls a routine part of their medical practice and by being available free of charge 24/7, thus changing the nature of doctor-patient relations. As a result, they have forced the re-examination of societal values and the structure and functioning of the health systems and the medical profession within the countries to which they were sent and where they continue to practice. This is the current Cuban threat.

Over the past forty-five years, Cuba’s conduct of medical diplomacy has improved the health of the less privileged in developing countries while improving relations with their governments. By the close of 2005, Cuban medical personnel were collaborating in 68 countries across the globe. Consequently, Cuban medical aid has affected the lives of millions of people in developing countries each year. And to make this effort more sustainable, over the years, thousands of developing country medical personnel have received free education and training either in Cuba or by Cuban specialists engaged in on-the-job training courses and/or medical schools in their own countries. Today, over 10,000 developing country scholarship students are studying in Cuban medical schools. Furthermore, Cuba has not missed a single opportunity to offer and supply disaster relief assistance irrespective of whether or not Cuba had good relations with that government. This includes an offer to send over 1000 doctors as well as medical supplies to the United States in the immediate aftermath of Hurricane Katrina. Although the Bush administration chose not to accept the offer, the symbolism of this offer of help by a small, developing country that has suffered forty-five years of US hostilities, including an economic embargo, is quite important.

Symbolic Capital and Symbolic Politics: the Context for Medical Diplomacy
Because good health is necessary for personal well-being as well as societal development, the positive impact of Cuba’s medical aid to other countries has greatly improved both its bilateral relations with those countries as well as its standing and support in a number of multilateral forums. Therefore, as a consequence of its medical diplomacy Cuba has accumulated considerable symbolic capital (goodwill, prestige, influence, credit and power). The creation of symbolic capital requires an initial investment of material capital as well as time in a given project, such as the efforts mentioned above. The resulting symbolic capital may be accumulated, invested and spent just like material capital. Eventually, it can be converted into material capital, which in Cuba’s case has meant both bilateral and multilateral aid as well as trade, credit and investment. This is one of the rewards for the conduct of medical diplomacy.

From the outset of the revolution, Fidel has made the health of the individual a metaphor for the health of the body politic. Therefore, he made the achievement of developed country health indicators a national priority. Rather than compare Cuban health indicators with those of other countries at a similar level of development, he began to compare them to those of the United States. This was particularly true for the infant mortality and life expectancy rates. Both are considered to be proxy indicators for socioeconomic development because they include a number of other indicators as inputs. Among the most important are sanitation, nutrition, medical services, education, housing, employment, equitable distribution of resources, and economic growth. It is, therefore, symbolically important for Cuba to compare favorably with the US in an effort to demonstrate what Fidel sees as the moral superiority of Cuba’s social development policies.

This striving for first world health has been so important that in many of his major speeches, Fidel has dedicated considerable time to discussing his island’s health indicators. His annual July 26 speech this year, given right before his own serious illness was made known to the public, was no exception. In it, Fidel cited the latest data: Cuba’s infant mortality rate was 5.6 per 1000 live births, a figure less than that of the United States, which was 7.0 per 1000 live births according to the latest published data (NCHS 2005, data are for 2002). Life expectancy at birth in Cuba today is the same as for US citizens, 77 years. These achievements make Cuba a model and therefore make possible its medical diplomacy.

In the past thirty-five years Cuba has tripled its number of health care workers. Even more striking is the change in the ratio of doctors to population. This went from one doctor for every 1,393 people in 1970 to one doctor for every 159 people in 2005. This was part of Fidel’s 1984 family doctor plan to put a doctor on every block. Having accomplished this in both urban and rural areas, even isolated ones, Cuba is now exporting this model through its medical diplomacy initiatives.

Cuba’s accomplishments in health realms are not just in primary care or in the production of doctors. There was a simultaneous development of high tech medicine and biotechnology as well. Cuba shares its expertise through numerous international medical conferences that it holds every year and through scientific exchanges. Because research is also an important part of the operation of the health system, in the medical and public health field alone, Cuba publishes fifty-four professional journals.

As early as 1982, the US government recognized Cuba’s success in the health sphere in a report that affirmed that the Cuban health system was superior to those of other developing countries and rivaled that of many developed countries. Despite economic hardship during the 1990s after the dissolution of the Soviet Union and the subsequent loss of its preferential economic relations along with the tightening of the then three- decade-old US embargo, Cuba continuously increased its spending on domestic health as a percentage of total government spending in order to shield the most vulnerable population from the worst effects of the crisis. As a result, the initial deterioration in the population’s health status was short-lived and the health indicators quickly improved. Today, even some US analysts who oppose Fidel Castro agree that Cuba’s health system has produced impressive results despite the many material shortages that it always has faced. Some critics also recognize, albeit reluctantly that Cuban medical diplomacy is producing positive effects in the recipient countries.

Selected Examples of Cuban Medical Diplomacy
Perhaps as a portent of things to come, even during the 1970s and 1980s Cuba implemented a disproportionately larger civilian aid program (particularly medical diplomacy) than its more developed trade partners: the Soviet Union, the Eastern European countries and China. This quickly generated considerable symbolic capital for Cuba, which translated into political backing in the United Nations as well as material benefits in the case of Angola, Iraq and other countries that could afford to pay fees for professional services rendered, although the charges were considerably below market rates.

Early success with medical diplomacy and the accumulation of symbolic capital as well as the ability to convert it into material capital, led Fidel to announce in 1984 that Cuba would train 10,000 new doctors specifically to increase the volume of international medical aid. No country other than Cuba has developed doctors as an export commodity. This has paid off handsomely both for the government of Cuba and for the individual doctors involved, as they usually earn considerably more money abroad than in Cuba.

The Cuba-Venezuela-Bolivia Connection
It is, indeed, ironic that in 1959 Fidel unsuccessfully sought financial support and oil from Venezuelan president Rómulo Betancourt. It would take forty years and many economic difficulties before another Venezuelan president, Hugo Chávez, would provide the preferential trade, credit, aid and investment the Cuban economy desperately needed. This partnership is part of the Bolivarian Alternative [to the US] for the Americas (ALBA) to unite and integrate Latin America in a social justice-oriented trade and aid block under Venezuela’s lead. It also has created an opportunity to expand Cuba’s medical diplomacy reach well beyond anything previously imaginable despite Fidel’s three-decade-long obsession with making Cuba into a world medical power; an obsession which was analyzed and documented in my 1993 book, Healing the Masses: Cuban Health Politics at Home and Abroad.

By far the largest Cuban medical cooperation program ever attempted is the present one with Venezuela under Hugo Chávez. The symbolic and material payoffs for Cuba are clearly demonstrated, for example, by the oil-for-doctors trade agreements between the two countries. The accords allow for preferential pricing for Cuba’s exportation of professional services vis-à-vis a steady supply of Venezuelan oil, joint investments in strategically important sectors for both countries, and the provision of credit. In exchange, Cuba not only provides medical services to unserved and underserved communities within Venezuela (30,000 medical professionals, 600 comprehensive health clinics, 600 rehabilitation and physical therapy centers, 35 high technology diagnostic centers, 100,000 ophthalmologic surgeries, etc.), but also provides similar medical services in Bolivia on a smaller scale at Venezuela’s expense. And to contribute to the sustainability of these health programs, Cuba will train 40,000 doctors and 5,000 healthcare workers in Venezuela and provide full medical scholarships to Cuban medical schools for 10,000 Venezuelan medical and nursing students. An additional recent agreement includes the expansion of the Latin American and Caribbean region-wide ophthalmologic surgery program (Operation Miracle) to perform 600,000 eye operations over ten years.

The main medical aid programs are the provision of comprehensive health services throughout Venezuela through the Barrio Adentro programs (Barrio Adentro I and II). As of March 25, 2006, there were a total of 31,390 medical personnel (mostly doctors) providing services through Barrio Adentro I, the primary health care program. Of that number, 23,382 were Cubans and the 8008 were Venezuelan. These Cuban “medical diplomats” had conducted 171.7 million medical consultations, of which 67.9 million were carried out in the communities (schools, workplaces, and homes). They visited 24.1 million families at home, something previously unheard of on that scale and in those locales. Moreover, these personnel provided 103.1 million health educational activities as well.

During the same period, under Barrio Adentro II, which provides medical diagnostics and physical therapy and rehabilitation, 10,856 histological exams were conducted, 84.4 million clinical laboratory exams were done, 808,153 CAT scans and 47,454 nuclear magnetic resonance exams were performed, among others. The newly established Comprehensive Diagnostic Centers handled 886,609 emergency room visits and performed 7.2 million diagnostic exams; and the Comprehensive Rehabilitation Wards also established under Barrio Adentro II handled 520,401 rehabilitation consultations and applied 1.6 million rehab treatments.

The second largest medical cooperation program is with Bolivia, where in June 2006, 1,100 Cuban doctors were providing free health care, particularly in rural areas, in 188 municipalities, mainly in the departments of La Paz, Santa Cruz, Cochabamba and Chuquisaca. Cuba already has provided the National Ophthalmologic Institute in La Paz with modern equipment and specialized personnel who, along with Bolivian doctors and recent graduates from the Latin American Medical School (ELAM), have treated over 1,500 patients free of charge. New accords stipulate the opening of two additional ophthalmologic centers, one in Cochabamba and another in Santa Cruz. They each will be able to treat 50 patients a day and the La Paz center will allow doctors to attend to 100 patients a day. As a result, Bolivia will have the capacity to perform ophthalmologic operations on a minimum of 50,000 patients annually.

Cuban sources indicate that by the end of July their medical team had attended one million Bolivians free of charge (to the patient) and had performed 23,000 ophthalmologic operations. Additionally, Cuba offered 5,000 more full scholarships to educate doctors and specialists as well as other health personnel at ELAM in Havana. At present, there are some 500 young Bolivians studying at the school and another 2,000 have started the pre-med course there. The six-year medical school program is provided free for low-income students who commit to practice medicine in underserved communities in their home countries upon graduation.

During the ELAM’S first graduation last August, Venezuelan President Hugo Chávez announced that his country will establish a second Latin American Medical School, so that jointly with Cuba, the two countries will be able to provide free medical training to at least 100,000 physicians for developing countries over the next 10 years. The humanitarian benefits are enormous, but so are the symbolic ones. Moreover, the political benefits could be reaped for years to come as students trained by Cuba and Venezuela become health officials and opinion leaders in their own countries. Today, medical students whom Cuba trained as doctors in the 1970s, are now in positions of authority and increasing responsibility.

Other Western Hemisphere Examples
Cuban medical teams had worked in Guyana and Nicaragua in the 1970s, but by 2005 they were implementing their Comprehensive Health Program in Belize, Bolivia, Dominica, Guatemala, Haiti, Honduras, Nicaragua, and Paraguay. Throughout the years, Cuba also has provided free medical care in its hospitals for individuals from all over Latin America and not just for the Latin American left. Please consult the bottom of this report for a list of countries for which Cuba has provided some type of medical assistance as of December 2005.

Under Haitian President Rene Préval, Cuba began its medical cooperation with Haiti in 1998. Currently, there are approximately 400 Cuban medical professionals working in Haiti on two-year assignments in 110 of the 164 comunes across the island. The program costs the Haitian government approximately US$1.8 million annually, which averages out to cost US$375 per month for each medical professional plus room and board, transportation and exemption for airport departure taxes. Because money is fungible, it is not evident which donor is providing the funding. Although very inexpensive by international standards, this program is relatively costly for the cash-strapped Haitian government and could become even more so if it is expanded as has been discussed recently.

Jamaicans, among others, with little means have been going to Cuba for free eye surgery as part of Operation Miracle. A spokesperson for the Jamaican Health Ministry has indicated that they had received positive feedback on the surgeries that had been administered. The number of patients reported with complications amounted to fewer than three per cent of the 1,854 patients who were treated in Cuba as of 2006.

As previously mentioned, Cuba has offered disaster relief over the years to every country that has experienced an emergency. And most often the offer has been accepted. A recent (2005) example is Guyana, where Cuba sent a team of 40 medical doctors and technicians to provide disaster relief after severe flooding had been recorded in the country.

Because Cuba has been successful in developing health programs at home and has provided medical aid abroad, often under difficult circumstances, some donor countries are willing to provide financial support for Cuban medical assistance in third countries in what is called triangular cooperation. Germany has provided funding for Cuba to develop health programs in Niger and Honduras. France provided some funding to execute a health program in Haiti. Japan provided two million doses of vaccines to vaccinate 800,000 children in Haiti and US$57 million to equip a hospital in Honduras where a Cuban medical brigade works.

Multilateral agencies, such as the World Health Organization (WHO) and the Pan American Health Organization (PAHO) also finance medical services provided by Cuba for third countries. Both organizations provided funding for Cuba’s medical education initiatives. Finally, Cuba’s Comprehensive Health Program, which is being exported to various countries that receive Cuban medical assistance, is supported by 85 NGOs and through triangular cooperation with both governments and NGOs, has received US$2.97 million in support. Although some of the amounts are small, it is clear that donors find that support for Cuba’s medical diplomacy makes professional sense.

Medical Diplomacy Outside of the Western Hemisphere
Cuba dispatched very large civilian aid programs in Africa to complement its military support to Angola and the Horn of Africa in the 1970s and early 1980s. With the withdrawal of troops and the later geopolitical and economic changes of the late 1980s and the 1990s, Cuba’s program was scaled back, but remained. Having suffered a post-apartheid brain drain (white flight), South Africa began importing Cuban doctors in 1996. Already in 1998 there were 400 Cuban doctors practicing medicine in townships and rural areas. By 2004, there were about 1200 Cuban doctors working in African countries, including in Angola, Botswana, Cape Verde, Côte d’Ivoire, Equatorial Guinea, Gambia, Ghana, Guinea, Guinea-Bissau, Mozambique, Namibia, Seychelles, Zambia, Zimbabwe, and areas in the Sahara.

On the African continent, South Africa is the financier of some Cuban medical missions in third countries. This South African-Cuban alliance has been much more limited in scope than the Venezuelan-Cuban deal. Discussions on the extension of Cuban medical aid into the rest of the African continent and a trilateral agreement to deploy over 100 Cuban doctors in Mali with US$1 million in South African financing, were concluded in 2004. Rwanda was to be next in a similar agreement. Cuba also had deployed 400 medical doctors to Gambia. As of December 2005, Cuba was implementing its Comprehensive Health Program in Botswana, Burkina Faso, Burundi, Chad, Eritrea, Gabon, Gambia, Ghana, Guinea-Bissau, Guinea-Conkary, Equatorial Guinea, Mali, Namibia, Niger, Rwanda, Sierra Leone, Swaziland, and Zimbabwe.

Cuban medical teams also have worked in East Timor since 2004 to create a sustainable health system. Currently, 182 medical professionals are providing a variety of services in Cuba’s Comprehensive Health Program. At the same time, Cuba offered full medical school scholarships for 800 East Timorese students to begin work on the sustainability of their program.

Recent Cuban disaster relief medical missions are still providing assistance in post-tsunami Indonesia and post-earthquake Pakistan. Shortly after the tsunami, Cuba sent a medical team and equipment to provide disaster relief. At the time, the team was handling over 150 consultations daily in a military field hospital and a polyclinic. They also were providing some preventive as well as curative care on their visits to refugee camps. Less than a week after the devastating October 2005 earthquake in Pakistan, Cuba sent a team of highly experienced disaster relief specialists comprised of 2300 doctors, nurses and medical technicians. Part of the team worked in refugee camps and Pakistani hospitals. The rest worked in 30 field hospitals located across the earthquake-stricken zone. The team brought everything they would need to establish, equip, and run those hospitals. The cost to Cuba was not insignificant. Two of the hospitals alone cost half a million dollars each. Only recently (May 2006), Cuba sent 54 emergency electrical generators as well.

In the past Cuba has also provided aid to Armenia, Iran, Turkey, Russia, as well as to most Latin American countries that have suffered either natural or man-made disasters. This type of medical diplomacy in the affected country’s time of need has garnered considerable bilateral and multilateral symbolic capital for Cuba, particularly when the aid is sent to countries considered more developed.

In Search of Sustainability: Provision of Medical Education and Training in Cuba and Abroad
In an effort to have a more sustainable impact on the health of the aid recipient countries’ populations as well as a multiplier effect on the immediate aid given, medical education always has been an important part of Cuba’s medical diplomacy. Education and training consist of on-the-job training, seminars, courses and full medical education. As early as the 1970s, Cuban medical professors either established medical schools or taught in medical faculties in Angola, Ethiopia, Guinea-Bissau, Nicaragua, and Yemen. This has been a continuing process ever since.

Cuba has long provided total scholarships for students from other developing countries to study anywhere from secondary school (medical technicians) through post-graduate studies. From 1961 to 2001, almost 40,000 foreign scholarship students had graduated in various medical disciplines from Cuban schools. Of those, 16,472 graduated from institutions of higher education. These numbers peaked in the 1980s before the fall of the Soviet Union. Now, with an oil-for-services agreement with Venezuela, Cuba is vastly increasing its scholarship offerings.

The Latin American Medical School (ELAM) was established in 1998 specifically to train students from poor communities in Latin American and African countries. In exchange for full scholarships, these students must be willing to return to their countries and practice medicine in poor communities for at least five years. After meeting with members of the US Congressional Black Caucus a few years ago, Fidel announced a symbolically significant plan for medical diplomacy with the United States: 500 full scholarships to Cuba’s ELAM for US minority students. Half of the scholarships would be for African Americans and the other half divided between Hispanics and American Indians. So far only a few Americans have accepted the offer.

There were a total of 10,661 foreign medical students from 27 countries studying in Cuba at the ELAM during the 2005-2006 academic year. Of this total, 10,084 were enrolled in medicine, 67 in stomatology (dentistry), 134 in nursing, and 376 in health technology. This is triple the number of medical students enrolled in 2002. To train French-speaking Africans and Haitians, the Cuban Government established the Facultad Caribeña de Medicina (Caribbean Medical School) in Santiago de Cuba, where 254 Haitians and 51 Malian students were studying in 2002.

Graduates from these medical schools take the National Final Cuban Examinations (NFCE) at the end of their program and then do an internship in their home countries. After that, they must take their home country’s qualifying exam just as all other medical students must do to be licensed to practice medicine. Reports from Chile, which has one of the most highly developed health systems in Latin America and a rigorous university system and medical licensing requirements, indicate that the first seven Chilean medical students who have graduated from ELAM and returned to Chile have had their degrees validated by the University of Chile as required and have entered successfully into Chile’s public health system. This suggests that the quality of education provided at the ELAM is high. The fact that Cuban doctors who have found work in Chile on an individual basis have had their credentials validated by the University of Chile in what one Chilean official said was a complicated and demanding process, attests to the overall quality of Cuban medical education.

Medical Diplomacy Wins Friends But Also Makes a Few Enemies
Medical diplomacy primarily wins friends among the governments whose people receive the aid and the patients and students who directly and individually benefit from it. But not all are thrilled to have Cuban doctors in town. In particular, local medical associations and individual doctors have harshly criticized the Cuban presence because of their competition for jobs, their different manner of working and treating patients, and because of the perquisites they receive (principally, free room and board). In some cases, such as in Bolivia and Venezuela, these medical associations have gone on strike to protest the Cuban presence. In these and some other cases, such as in South Africa and Haiti, they have taken their complaints to the press. Despite protests (and strikes), numerous press and other reports from different countries extol the benefits to the patients, many of whom had never seen a doctor before, particularly living and working in their own neighborhood.

Not surprisingly, these medical associations sometimes seek to discredit the Cubans and use what appears to be a technical argument, the questioning of certification standards (credentials) and quality of care. Medical licensing is a standard practice in all countries, but it can be and is used by some who feel threatened by the competition of Cuban doctors willing to serve in areas that they themselves would not go, let alone work. On the other hand, standards are important and ideally, there should be a WHO or other supra-national independent accreditation agency that could establish criteria for and validate medical degrees and licenses or establish equivalences so as to eventually allow for global labor mobility. This, however, would be extremely difficult to negotiate and is unlikely to occur in the next few decades. Therefore, Health Ministries, or, in some cases, medical associations become the gatekeepers for entry into the profession. This is tricky when vested interests are in charge of the licensing or accreditation process or are politically strong enough to block it. In 2003, the Venezuela Medical Federation, which is ideologically opposed to the Chávez government and the Barrio Adentro medical program, filed a lawsuit to prohibit Cuban doctors from practicing medicine there. The court held in favor of the Medical Federation, but the Venezuelan government did not back down.

Similarly, in Bolivia, when the Colegio Médico de Bolivia and the association of unemployed doctors went out on strike to protest the presence of the Cuban doctors, President Evo Morales asserted publicly that the Cubans would stay as long as he is in office. He also exhorted the Colegio Médico to change its attitude and to “pay” with their professional services for their free medical education in public universities paid for by Bolivian taxpayers. Like in the case of Venezuela, the benefits to the host society far outweigh the costs to the local medical professions, which in these two cited cases are ideologically opposed to the government.

At the urging of the Haitian medical association, the previous government asked for a revision of the cooperation agreement to include better control by the Ministry of Health over the mix and quality of medical staff sent as well as the nature of their work in the field. However, this revision has yet to take place. Some malpractice accusations have been made against Cuban doctors in Venezuela, South Africa, Zimbabwe, and Haiti. A much-publicized case in Venezuela proved to be the fault of opposition doctors who refused to treat a patient referred to a hospital by a Cuban doctor. On the other hand, it is quite possible and, indeed, probable that there are some genuine cases that need to be addressed. This would be normal among all cohorts of practitioners and should be properly investigated and remedied.

Rewards For Medical Diplomacy
As stated at the outset of this article, Cuba’s rewards are symbolic and material capital. There is enormous prestige and influence in determining the direction of public health systems in the countries in which Cuba practices medical diplomacy. The training of future leaders in the medical field assures Cuba of on-site support in the future. More importantly, Cuba’s medical diplomacy contributes to the positive views held by other governments as translated into voting results at the United Nations on issues of particular importance to Cuba, such as an end to the US embargo of Cuba and the stressing of human rights issues. Importantly, Cuba was elected to the new UN Human Rights Council by direct, secret ballot in which all member states were elected individually and not in blocs.

In a press conference reported in the daily Última Hora, Paraguayan President Nicanor Duarte Frutos explained why his country would abstain rather than vote in favor of the US sponsored anti-Cuba resolution at the UN Human Rights Commission in Geneva, despite President Bush’s personal call in April 2004 asking for his support. The reason: a cooperation agreement with Cuba dating back more than six years, whereby Cuban doctors provide medical assistance in Paraguay and Paraguayan youths from very poor families are studying in Cuba on scholarships. At that time, there were 600 students involved in the program.

With regard to the US embargo of Cuba, the US State Department’s own data show that in the 2005 General Assembly votes, only Israel, the Marshall Islands and Palau supported the US position. This was the fourteenth consecutive time in which the US position was rejected, but to no material benefit to Cuba since the US has been going it alone for a long time now on this issue. Among Cuba’s trade and aid partners, voting coincidence with the US generally ranked only between 6 and 22 percent during 2005. The overall average coincidence for all countries was only 25%. The LAC average was 19.7%. The Asian group average was 18.7%; the African group averaged 13.5%; the Eastern European group averaged 40.4%; and the Western European and Others (Australia, New Zealand) came in at 46.7%. Cuba’s medical diplomacy should be seen as contributing to this pattern. Rather than isolating Cuba, it is the US that is becoming more isolated on this issue.

Far from being marginalized by Washington’s anti-Havana offensive, Cuba has remained an important member of the Non-Aligned Movement and once again has just hosted the summit of heads of state and government in September and has become the leader of the NAM for the next several years. Cuba previously hosted and led the NAM in 1979. Also Fidel attended the July 2006 MERCOSUR summit, which opened with the signing of a trade agreement with Cuba for mutual preferential market access. The agreement consolidates the already existing bilateral agreements on preferential tariffs that Cuba has had with each of the MERCOSUR members. Although the amount of trade between Cuba and MERCOSUR is not great, the agreement is significant for its timing: just before the release of the US-sponsored Commission for a Free Cuba’s tough report on tightening the US embargo and promoting regime change.

More importantly from an immediate standpoint are the export earnings deriving from medical diplomacy. Data on the amount paid for the various activities involved in Cuban medical diplomacy has always been difficult to establish. Rates paid for doctors have ranged from nothing where the country could not afford to pay, to some rate well below market prices. Nonetheless, rough estimates suggest that the amounts are truly significant and have surpassed earnings from tourism. The Economist Intelligence Unit estimates that the increase in non-tourism services exports between 2003 and 2005 was around US$1.2 billion for a total of US$2.4 billion, which puts non-tourism services ahead of gross tourism earnings (of US$2.3 billion) in 2005. Most of this is medical services.

Official data for export earnings from medical products (medicines and equipment) were below US$100 million in 2004, but there have been press reports citing a figure of US$300 million for such products. Cuba exports medical biotechnology products to 40 countries, but sales data were not available. Two important earnings streams not included in the export data come from the licensed manufacture of Cuban medicines in other countries and joint-venture production facilities abroad. Officials in Havana have indicated that these are significant, but no concrete data is available. Cuba has some licensing agreements, including one in the US for anti-cancer drugs, and even joint venture production facilities in China. Also, treatment facilities are being built in other countries, particularly in the field of ophthalmology, under agreement with Venezuela. The oil-for-doctors agreement is very lucrative for Cuba because of preferential pricing for Cuba’s professional services exports and because Venezuela absorbs the loss for any escalation of oil prices, a factor that has occurred to a considerable degree in recent months. Commercial trade between Venezuela and Cuba surpassed US$ 2.4 billion in 2005 and US$1.2 billon in the first trimester of 2006. Also, on the aid side between 2002 and 2006, Cuba has received some US$50 million for a range of physical development programs from the Organization of Petroleum Exporting Countries Fund. These rewards make medical diplomacy well worth the effort, not to also mention the important humanitarian benefits.

The Cuban Challenge
Taking medical diplomacy a degree further, at the recent MERCOSUR summit in Córdoba, Argentina, Fidel called for a social agenda to globalize solidarity in health and education. He offered Cuba’s experience in health and education to support that agenda. In these remarks, he laid down a gauntlet not only for MERCOSUR, but also for his adversary, the US government. It appears, however, that no one will take him up on it.

Post-Fidel Medical Diplomacy
Fidel transferred power to his slightly younger brother Raúl Castro just days before the Non-Aligned Movement meeting was convened in Havana. Indications are that although Raúl is the heir apparent, something approaching a de facto collective leadership most likely will govern Cuba in the near future. This leadership group probably will include not only Raúl, but also Ricardo Alarcón, who presides over the National Assembly of People’s Power; Carlos Lage, Vice President; and Foreign Minister Felipe Roque Pérez. None of these figures is expected to alter significantly Cuba’s practice of medical diplomacy in the near term. As long as the export of excess Cuban doctors continues to provide both material capital (e.g., oil-for-doctors) and symbolic capital (e.g., support in international forums), it is likely to be maintained. However, the scale of this program depends more on Hugo Chávez’s largesse than on Cuba’s willingness to continue it.

The temporary export of Cuban doctors also provides a safety valve for disgruntled medical professionals who earn much less at home than less skilled workers in the tourism sector. Their earning opportunities abroad are significant both within the confines of medical diplomacy and even more so, beyond it. This has led to a number of defections, allegedly around six hundred, although some say this figure is too high. This figure could grow if Cuban-American activist groups carry out their threats to assist these doctors serving in foreign lands if they defect. Should this number increase dramatically in this period of political change, the Cuban government may decide that the cost is too great to bear. In an effort to break the oil-for-doctors bond that supports the Cuban economy and create a medical brain-drain, the Bush Administration announced (on August 7) a possible change in its Cuba policy to ease immigration for Cuban doctors who participate in Cuba’s medical programs abroad. This is in sharp contrast to its tightening of policy regarding immigration of Cubans who enter the U.S. illegally. The lure of vastly increased earnings, easy access to high technology, and a much better material quality of life may lead doctors born, raised and trained at great expense in revolutionary socialist Cuba to cease helping those in need in developing countries and depart en masse. If they do, this is unlikely to break the ties that currently bind Cuba and Venezuela. But, this will raise questions about the consistency of US immigration policy. The fact that the Bush administration is trying to destroy Cuba’s medical diplomacy program indicates that the program works. Rather than attempt to destroy it, the Bush administration should emulate it.

Countries in which Cuba provides collaboration in Health by region, December 2005

The Americas
Antigua and Barbuda, Argentina, Aruba, Bahamas, Belize, Bolivia, Brazil, Colombia, Costa Rica, Dominica, Ecuador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Venezuela, Dominican Republic, St. Kitts and Nevis, St. Vincent and the Grenadines, St. Lucia, Suriname, Trinidad and Tobago

Africa
South Africa, Angola, Botswana, Burkina Faso, Burundi, Cape Verde, Congo, Djibouti, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Equatorial Guinea, Guinea-Bissau, Guinea, Lesotho, Mali, Mozambique, Namibia, Niger, Rwanda, Sao Tome and Principe, Seychelles, Sierra Leone, Swaziland, Chad, Uganda, Zimbabwe, RASD, Algeria

Asia
Qatar, Yemen, Laos, Pakistan, East Timor, Indonesia

Europe
Italy, Switzerland, Ukraine

Source: Statistical Registers of the Central Medical Cooperation Units, 2005 Statistical Yearbook of the Cuban Ministry of Public Health

Julie M. Feinsilver is the author of “Healing the Masses: Cuban Health Politics at Home and Abroad” (Berkeley: University of California Press, 1993). Dr. Feinsilver is a Senior Research Fellow at the Council on Hemispheric Affairs in Washington, DC, and an international civil servant. The views expressed herein are solely her own and do not necessarily reflect those of any institution with which she is affiliated.

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