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Cuba’s Health-Care Diplomacy: The Business of Humanitarianism

For decades Cuba has exported workers to the developing world as “missionaries for the Cuban Revolution.” Usually sent on two-year tours, they are predominantly health professionals, although teachers, sports trainers, engineers, architects, and other specialists also serve. The goal is to earn hard currency and advance other financial goals of the regime while gaining influence, prestige, legitimacy, and sympathy abroad.

The initiative began in 1960, when the relatively new revolutionary government of Cuba sent medical brigades to Algeria during the civil war with France and to Chile after a devastating earthquake. Havana realized it had stumbled onto a winning strategy: the state could mobilize health workers at very short notice and send them practically anywhere, including hardship locations, make them work under unique terms, and have them stay as long as necessary. The care they provided was an advertisement for socialism, especially for the Cuban brand, and a way to strengthen ties with their host nations. Government-to-government cooperation agreements soon guaranteed a more permanent and larger foreign presence for the Cuban “collaborators.”

Medical training and instruction also became part of the deals Cuba brokered primarily with third-world countries facing a scarcity of doctors and health workers. By allowing officials and politicians in host countries to secure needed health care at a relatively low cost, delivered in areas where local doctors and international volunteers do not go, Cuba reaped the benefits as support in terms of public praise and hard-currency payments and, eventually, international aid, trade, credits, and investment.

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Cuba claims that from 1961 to 2008, 270,743 Cubans had worked in one hundred and fifty-four countries, and official sources report that there are between thirty-eight and forty thousand health workers in sixty-eight to seventy-seven countries, fifteen to seventeen thousand of them doctors. While these numbers are not independently confirmed, it is indisputible that in the last decade, Cuba’s health diplomacy greatly expanded thanks to Hugo Chávez. In 2000, soon after he was elected president of Venezuela, Chávez signed the first cooperation agreement with Cuba, establishing the basis for a close economic and political alliance. Beginning in 2002, successive annual agreements with Venezuela have institutionalized Cuba’s international health services, providing critical aid to Cuba’s ailing economy and boosting loyalty and support for the Chávez-Castro revolutionary project.

Under the bilateral agreements, Cuban professionals are paid by Venezuela to provide health care free of charge to large underprivileged populations in Venezuela and other ALBA countries as well as medical training in Cuba and Venezuela. This is done under the aegis of the Boliviarian Alliance for the Americas (ALBA), which seeks the integration of the Caribbean and Latin America in “an alternative model to neoliberalism,” which many consider a code term for Marxism-Leninism.

Aside from an extensive deployment of Cuban health workers in Venezuela, other countries whose presidents have strong ties to Venezuela and Cuba—Bolivia, Ecuador, Nicaragua, and, most recently, Argentina—have been given access to Cuban health care. Patients are flown to Cuba or Venezuela for treatment, all expenses paid, or treated at hospitals and clinics donated to their countries by the Chávez government, fully staffed and stocked by Cuba. A gigantic vision restoration program was also launched in 2005, “Operation Miracle,” in which Cubans, and more recently Venezuelan specialists they’ve trained, perform surgeries for cataracts, glaucoma, and other eye ailments. Its goal is to complete six million operations in the Americas (including three million in Venezuela) by 2015.

Thanks to the alliance with Chavez, the number of reported Cuban health collaborators grew steeply from 6,190 in 2002 to 31,243 in 2005. The program reached its peak in December 2008, when 29,296 Cuban health professionals were said to be serving just in Venezuela, 13,020 of them doctors. Since then, official sources report a steady number of thirty thousand health workers as part of a total forty to fifty thousand Cuban collaborators in Venezuela.

According to reports from Havana and Caracas, from 2000 to 2010 close to two million Venezuelans were treated by Cuban medical personnel or by Venezuelans trained by or working with them, and 24,800 Venezuelan doctors were trained in Cuban medical schools. By 2012, Operation Miracle had treated almost a million and a half people from thirty-five countries, including more than two hundred and sixty-seven thousand foreigners in Cuba, and sixty-one eye hospitals had been donated to twenty-two countries.

Fidel Castro and other Cuban officials had long lauded the idealistic fervor of the medical teams sent abroad, referring to their “volunteer” services performed “for free.” For years it had been a state secret that Cuba keeps a sizable part of the payment it receives for its “proletarian internationalists.” But, in 2010, official Cuban sources started discussing these revenues in the context of their importance to the economy. A need to explain the large export services appearing in the national accounts, a proliferation of news reports referring to the payments, and the lingering absence of health workers in Cuba apparently convinced them it was impossible to maintain the ruse any longer.

Agreements with host countries are kept secret, but some details of the income generated for Havana have emerged over the years. Terms vary depending on the country, but typically the host country pays Cuba a hard-currency sum for each health worker; currently, for example, it has been reported at $5,000 (US dollars) in Angola and $2,784 in Namibia. Haiti does not pay Cuba directly; instead, NGOs, other governments, and international organizations fund Cuba’s medical brigade, and apparently with many millions of dollars.

The host government provides each internationalista furnished housing, domestic transportation, and a monthly stipend generally between $150 and $500 for food and personal expenses. Cuba covers logistical support and sometimes airfare, plus pays the family of the collaborator back home their regular peso salary—a scant $22 to $25 a month on average for a doctor—and a hard-currency bonus of around $50 to $120 monthly.

As an added benefit, the government allows the internationalists to send home some consumer goods free of import duties, which allows families to import appliances, electronic equipment, and other products nearly impossible to get in Cuba or only available at exorbitant prices. Some use these shipments as business opportunities to sell clothes and goods bought very cheaply abroad at high markups in Cuba. This paltry compensation package is sufficient incentive for grossly underpaid Cuban doctors to want to go abroad.

Venezuela’s arrangement is particularly generous to Cuba. Reportedly, Venezuela sends Havana around a hundred thousand barrels of crude oil per day. Cuba pays fifty percent of the balance due in ninety days with the services of its collaborators; the rest may be deferred, with Venezuela financing it for seventeen to twenty-five years at one-percent interest after a two-year grace period.

The large expansion of the international medical aid program resulting from the Venezuela agreement is reflected in Cuba’s seven hundred and seventy-two percent increase in export services from 2003 to 2010 (the latest year for which statistics are available). By 2005, these export services had surpassed tourism revenues; since 2008 they have been more than three times tourism revenues and generating far more income than any other industry (see Table 1).

Cuba has received financial assistance for its medical missions in countries such as Honduras, Haiti, Niger, Rwanda, and Mali from the governments of Germany, France, Japan, Norway, Australia, and others, as well as from multilateral agencies such as the World Health Organization, the Pan American Health Organization, and UNICEF, and from many international organizations in countries such as the US, Canada, Spain, and Belgium. From 2008 to 2010, Cuba reported receiving $713 million in aid, though it is unknown how much was for international health projects.

Many of the bilateral agreements include medical training, both in Cuba and in partner countries. In 2012, Cuba reported providing medical training in fifty countries. In addition, anywhere from twenty-three to fifty thousand foreign students are attending medical school in Cuba. Students come from dozens of developing countries and most seem to be on scholarships from their governments. Furthermore, in 2012 more than twenty-nine thousand students were said to be receiving training by Cuba in Venezuela, Bolivia, and several African countries.

 

The growth of export services under these arrangements has been phenomenal, but the consequences for Cuba’s economy have not all been beneficial. First, it greatly diminishes pressure for needed structural reforms. In addition, given the limited multiplier effect of these export services, it thwarts the allocation of resources to more stable and productive activities. Finally, it makes the economy excessively dependent on an external factor that could quickly disappear if there is regime change in Cuba or Venezuela.

Associated health-care arrangements provide additional financial rewards to Cuba not reflected as export services. Although details are lacking, it appears that some cooperation agreements include the provision by Cuba of medicines and medical supplies. The government does not reveal figures for this revenue stream, but it may be significant. (Cuba’s total exports doubled from $2.4 billion in 2004 to $4.6 bilion in 2010 with no other apparent explanation for the steep jump.) Cuba also derives revenues from the transportation of its collaborators to and from some of the destination countries. Namibia, for example, provides for each Cuban health worker $11,500 for international travel and cargo and excess baggage when traveling back home, with a good part of this sum presumably going to the Cuban government. Extra revenue is also generated by arrangements such as a 2008 and 2009 deal by which a specialized Cuban state enterprise provided all air and land transportation, accomodations, and other non-academic activities to Chilean public health workers sent to Cuba for training programs.

Cuba also derives considerable collateral benefits in trade and investments from its health diplomacy. Following the January 2010 earthquake in Haiti, for instance, Norway donated around $2 million to Cuba for supplies for its medical brigade in Haiti and soon after signed bilateral agreements relating to oil and fishing. In 2010, Cuba agreed to send two hundred health workers to staff two facilities in Qatar and soon a Qatari state company announced plans to build two $75 million hotels in Cuba and seek other areas of the economy to invest in.

In 2009, lower oil prices, a world recession, and the mounting toll of Bolivarian economic management and uber-spending had created serious liquidity problems for Chávez. Payments for Cuban professional services (applied to oil imports) were reduced, triggering a grave internal economic crisis in Cuba and a resolve by its government to increase its health services worldwide beyond Venezuela.

Havana’s global health presence began expanding at a feverish pace. Although countries such as Panama, Honduras, and Brazil had terminated cooperation agreements and sent the internationalists back home, new and more substantial Cuban health brigades proliferated in the English-speaking Caribbean, Africa, and the Arab world. The expansion is most noticeable in oil-producing countries such as Qatar, Algeria, Kuwait, and Angola, which can presumably pay more.

Cuba’s need to increase revenues was so urgent that late in 2010 its Ministry of Health announced a personnel reduction in the domestic health-care sector so that more doctors could be sent aboard “to earn hard currency.” (Official statistics later confirmed that in 2010 overall employment in the health sector fell fourteen percent from 2009.) The payoff was soon evident. For the first quarter of 2012, Cuba reported an eleven-percent growth in exports (seventy-five percent of which are medical services) compared to the same period the previous year.

Havana is also training foreign medical personnel in large and increasing numbers in Cuba and increasing the fees charged to foreign students. Other aggressive efforts are under way to increase revenues from medical diplomacy. The mission in Namibia is a case in point. In September 2012, the Namibian press reported that Cuba was asking close to fifty percent more per health worker; currently each of the fifty-two Cuban doctors and several hundred nurses, technicians, and technologists are paid $157,341 per two-year period. (The $8.2 million annually Cuba receives just for the doctors would rise to around $12 million under the new pricing structure.)

Efforts to raise revenues from health tourism are also obvious from heightened public relations efforts offering foreigners access to Cuba’s network of fifty-four hospitals “with the most modern technology.” State corporate entities sell packages for numerous medical conditions that include medical consultations, testing, and treatment plus all transportation, accommodations, and meals—a one-stop-shopping approach to wellness.

Further revenues are coming from greater international assistance for the international health programs. The medical mission in Haiti has been particularly successful. When the earthquake struck in January 2010, Cuba immediately sent a medical contingent to join its three hundred and forty-four health professionals already deployed throughout the country. A strong international response to support Haiti turned into a golden opportunity for Cuba. Weeks later, it was promoting, with Venezuela, a huge project to build Haiti a new health-care infrastructure with funds from international donors at a cost of $170 million per year. Cubans and Cuban-trained medical staff would run it “at half the international prices.” Cuba’s medical brigade in Haiti now has seven hundred and fifty health workers and is reportedly receiving tens of millions from hundreds of individual donors and NGOs, as well as from multilateral agencies such as the World Health Organization and the governments of Brazil, Norway, Australia, Namibia, and others.

 

There is no doubt that Cuban health workers provide vital services to many people. But a serious or comprehensive analysis of results is impossible because, as Cuban health professionals themselves relate, statistics are systematically tampered with and most reports by Cuban official sources are inconsistent and contradictory in addition to being loaded with revolutionary hyperbole and outlandish statistics. (Havana boasts of educating “more doctors than all the medical schools in the United States,” “saving four million lives over the past five decades,” and “caring for some seventy million people, in some cases the entire population of a country, such as in Haiti.”)

Most academic and media reports repeat the Cuban government’s claims verbatim, while host government officials and international supporters laud Cuba’s humanitarianism and promote its model. Extensive international public relations efforts in the US, Canada, and the UK involve dedicated and well-funded NGOs, websites, and films extolling the Cuban “miracle,” part of an echo chamber that also includes conferences and presentations at leading universities, and exchanges with and visits to Cuba that are tightly managed and feature only showcase facilities.

Few supporters acknowledge that Cuba’s brand of health diplomacy is possible only in a totalitarian state. With the state the sole employer, health professionals are forbidden from leaving the country without permission; issuing them proof of their medical studies and credentials is punishable by law. When they are sent on a foreign mission, they must leave their families behind as hostages to their return. With the average monthly salary of a doctor only around $25, barely guaranteeing subsistence, the system ensures a steady pool of temporary workers, “exportable commodities” primed for exploitation.

The health collaborators must often work very long hours, are under constant surveillance by handlers, and are subject to a long list of prohibitions—they may not drive a car, leave their dwellings after a certain hour, speak to the media, or associate with locals. They have political obligations in addition to their professional duties. In Venezuela, for instance, doctors have been charged with helping keep Chávez in power and informing on co-workers who bend any rules or are suspected of planning to defect. They must often share shabby or cramped quarters with local families or co-workers, lacking privacy and basic safety. In Venezuela in particular, they serve in crime-infested areas and many have been assaulted, raped, or killed. Sixty-eight Cuban doctors were killed in Venezuela between 2003 and 2010.

Their compensation is a minuscule fraction of what Cuba derives from their work, though it varies by country. Although Venezuela’s payment arrangements are still a close secret, for instance, doctors who escaped in August 2012 claim that while Venezuela pays Cuba $5,000 a month per doctor, each doctor receives only an estimated $900 to $1,740 a year, with specialists earning the highest amount.

Most health professionals agree to serve abroad in order to protect their job and career, save some money, have access to consumer goods to send home, and perhaps even find a viable route to escape. One doctor who served overseas before defecting wryly proclaims: “We are the highest qualified slave-labor force in the world.”

To prevent defections, the internationalists are issued a special passport that may not bear visas from any other country and is often held by supervisors. If caught trying to defect, they are forced back to Cuba. Nonetheless, thousands have deserted worldwide, many in dangerous and elaborate escapes, even though their families are kept hostage in Cuba and not allowed to join them. From 2006 to March 2010 almost sixteen hundred of these medical defectors had made it to the US alone under a special program that grants them entry for humanitarian reasons. The exodus continues: some eighty Cuban physicians a month were reportedly leaving Venezuela before the October 2012 presidential election there.

Ostensibly, the cooperation accords violate a number of international agreements (most ratified by Cuba), including the Trafficking in Persons Protocol and several International Labor Organization conventions, including the Protection of Wages Convention and Convention No. 29, which concerns forced or compulsory labor. They also trample on international standards concerning the prohibition of “servitude” and “slavery” and likely violate the domestic legislation of most host countries.

While the Cuban government profits from the labor of its medical brigade, Cubans at home suffer from lack of care. A critical lack of doctors, particularly specialists, has been widely reported in Cuba since the mid-2000s. Health facilities for average citizens are grossly underfunded, dilapidated, and lacking the most basic medical supplies and equipment. Cuban doctors who served in Venezuela have reported that weekly arrivals of military aircraft from home carry medical supplies not available to patients at home and in large amounts. Some tell of having to throw out unused supplies because they had to report having used them on fictitious patients to meet treatment quotas.

In some host countries, moreover, there is open disenchantment with Cuba’s health services. Because a high number of foreign graduates of Cuban medical schools are not passing board exams back home, many local medical associations question the quality of the training and the experience of Cuban doctors who work without the required credentials. Malpractice allegations have surfaced in several countries, yet patients who have had bad outcomes from treatment have little legal recourse.

Complaints are also heard on the economic irrationality of some of the bilateral arrangements. In Venezuela and Ecuador, homegrown doctors have been fired and replaced with Cubans. While Venezuelan doctors in the public health system earn around $940 per month, Cuba is purportedly being paid many times more per doctor, although the workers actually do not receive the pay. Bolivia’s and Paraguay’s medical associations have protested loudly that local doctors earn considerably less than the Cubans and that hundreds of Paraguayans have been flown to Cuba for eye surgeries that could have been performed by local doctors at ten times lower the cost. In August 2011 Ghana signed an agreement for Cuba to train two hundred and fifty doctors over a six-year period for roughly $55,000 annually per student, even though it costs seventy percent less to train them in Ghana.

Security concerns compound the darker side of Cuba’s international medical programs. Many of the internationalists, including some doctors, are trained by Cuban intelligence to monitor the host country and diffuse opposition to Cuba or the revolutionary project. Hundreds of members of Cuba’s armed forces and paramilitary groups have allegedly been trained in technical medical specializations to serve abroad. Sources close to the Martelly government of Haiti, for instance, claim that it is known that Cuban collaborators “play a double game” by collecting intelligence. The opposition to Chávez in Venezuela has long expressed concerns regarding the large Cuban presence, and in 2010 a former Chávez aide and newly retired brigadier general publicly denounced Cuba’s use of its personnel to meddle “at the highest levels in vital areas that compromised Venezuela’s national security.” That this view was not simply that of a political malcontent was shown when the Economist reported that Cuban agents occupied key posts in Venezuela’s military intelligence agency as well as its oil, petrochemical, and construction industries, and also that hundreds of Venezuelan youth were being trained in Cuba in the tactics of social repression and political control.

Cuba’s health diplomacy has been immensely successful in eliciting support for a Communist totalitarian state and huge resources for its failed economy. But it is also beginning to suffer, within and without Cuba, as a result of what the Marxists would call its own “internal contradictions.”

Maria C. Werlau is a New Jersey–based consultant and executive director of the nonprofit Cuba Archive.

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