Cuba's medical diplomacy
By Andrew Jack
Published: May 15 2010 00:21
When word reached Juan Carrizo that Hurricane Katrina had struck New Orleans on August 29 2005, he reacted with military precision. From his office in a former Cuban naval base just west of Havana, while Washington um-ed and ah-ed over its own response, he began mobilising specialists to assist the thousands of Americans affected by the disaster.
Cuba itself had been scarred by Katrina, but Carrizo's focus at the former Granma Naval Academy – a concrete campus on a balmy, palm-lined beach – was the other side of the Gulf of Mexico, as he helped to co-ordinate an unprecedented humanitarian mission to his country's giant neighbour and arch political rival. Within three days, Carrizo, dean of the Latin American Medical School (Elam), had assembled 1,100 doctors, nurses and technicians, and 24 tonnes of medicine, all ready to fly to Louisiana. They were dubbed the Henry Reeve Contingent, in honour of a New York-born Cuban hero who fought against the Spanish in the 19th century.
Fidel Castro, still president of Cuba at the time, said in a speech he made later that month: "Our country was closest to the area hit by the hurricane and was in the position to send over human and material aid in a matter of hours. It was as if a big American cruise ship with thousands of passengers aboard were sinking in waters close to our coast. We could not remain indifferent."
But the US didn't respond to the offer of assistance. It didn't even acknowledge it. "We prepared more than 1,500 doctors with all the necessary knowledge, equipment and supplies, who were ready to start work as soon as we entered the country," recalls Carrizo, shaking his head. "The US government didn't accept them, and many people died who could have been saved. That was a sad day for medicine, and for American society."
Since 1998, when Hurricanes Georges and Mitch devastated the Caribbean and Castro resolved to train one doctor for every person killed by the storms, Carrizo had been set to work establishing Elam, the Latin American Medical School. It has since trained more than 33,000 students from 76 countries, who then return home to practise, largely among poor patients. This year, for the first time, some of its foreign graduates formally joined Cuban medical specialists on Henry Reeve Brigade missions to Haiti and Chile, following the most recent earthquakes.
Such "medical diplomacy" has been part of Cuba's foreign policy almost since the revolution – and has grown in intensity over the past few years, fuelled above all by strong demand from Venezuela. In some of the most remote and neglected parts of the world, where western countries have "brain drained" away most of the medical expertise, Cuban personnel are winning friends while helping to fill a desperate need. In the past half century, some 130,000 have worked abroad, and today, 37,000 – half of them doctors, the rest nurses and other specialists – are spread across more than 70 countries. Now Elam is training many more from these nations too.
Havana's approach irritates many, including doctors in other countries who feel undermined by rivals parachuted in to provide free services, and western nations whose health systems are very differently structured. At home, Cuban doctors face modest pay and limited choices, tempting them to volunteer overseas despite regrets about abandoning their own communities and concerns over intimidation while abroad. Some have even defected, although Cuba's tough emigration controls seriously weaken the impact of the brain drain that prompts so many of their low-paid peers in other countries to pack their bags. Medical diplomacy is a potent form of "soft power" – but one with a hard edge.
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A short walk from Havana's historic Plaza de Armas, Dr Jose Anido Gusman sits in a two-room office awaiting patients, a fan easing the afternoon heat. On the wall, one poster describes several herbal medicines and their uses; another urges safer sex. Most strikingly, a chart at the rear lists relevant statistics for everyone in his neighbourhood: 3,390 residents in total; 1,191 at risk; 619 smokers; 321 sedentary. "We visit every family at least once a year in their home," says Anido Gusman, two years out of medical school. "That includes the healthy ones."
This is not new: it has been going on almost since Castro seized power. But it has intensified sharply in recent years as medical staff – whether Cuban or Cuba-trained – set about recreating this same model in their host countries. "The doctor is like a member of the family," says Dr Maria Fernandez Oliva, director of the nearby Thomas Romay polyclinic. From her office, decorated with posters of Fidel Castro, his brother Raúl (who became the country's president in 2008) and Che Guevara, she oversees Gusman's clinic and dozens of others across the district. She also manages the specialists in her own larger centre, a maze of rooms with rudimentary equipment colonising an old mansion block. "Doctors know patients socially, politically, religiously," she says. "They understand the biological, psychological and social aspects of illness. The key to the system is prevention. We solve 90 per cent of the population's problems here. If we can't fix a problem within a few hours, we send them to hospital."
The approach is labour-intensive, although less costly than it would be elsewhere because doctors' salaries average just $25 a month, forcing many to moonlight to make ends meet. Coupled with an exhaustive programme of vaccinations and broader efforts to tackle poverty, the system has led to sharp reductions in the rates of infectious diseases that remain significant killers in other parts of the Caribbean. The result has been to extend lives and create a pattern of illness and death very similar to that in the west. As Cubans joke, they live like the poor but die like the rich. "We are more worried about chronic diseases: obesity, hypertension, diabetes. Just look at me," says Fernandez Oliva, gesturing towards a body squeezed with difficulty into her white coat.
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Not everyone accepts the figures supporting Cuba's strong health performance, and critics of the regime argue that Castro's revolution set back a country that was already reporting progress in tackling disease. But the statistics of the 1950s were also partial, taking little account of the extremes of poverty and ill-health found in rural areas. The improvements over the half-century since came through centralisation and aggressive politics, implemented in the teeth of the disruption triggered by Castro's overthrow of the Cuban dictator Fulgencio Batista, the economic restrictions imposed by the US embargo and the evaporation of financial support from the Soviet Union after its collapse in 1991.
Cuba's medical history might appear an esoteric footnote, but it remains central to the leadership's contemporary political rhetoric, a symbol of pride and a tool in its international and domestic affairs. In the Havana convention centre last November, four rows of VIP seats quickly filled with senior representatives of the capital's embassies. They had come for the closing session of the Global Forum for Health Research, a meeting of academics, funders and policymakers, to hear José Miyar Barrueco, Cuba's minister for science, technology and environment. "One of the tasks of the leadership of the revolution was training health personnel," he began. "Half the doctors left. I don't have to tell you where to."
Health has played a big role in the politics of many countries, but rarely more so than in Cuba. In Havana's Museum of the Revolution, the former Presidential Palace, exhibition panels laud Antonio Guiteras Holmes, the US-born founder of the 1920s Revolutionary Union movement; he studied pharmacology in Cuba. Extracts from Castro's famous 1953 "history will absolve me" speech proclaim: "The state is most helpful – in providing early death for the people … Society is moved to compassion when it hears of the kidnapping or murder of one child, but it is indifferent to the mass murder of so many thousands of children who die every year from lack of facilities, agonising with pain."
An entire room in the museum is devoted to the world's most famous "medical guerrilla", Che Guevara, who studied as a doctor in Argentina before becoming a revolutionary in Cuba. He and his companions looked after not only their fellow fighters but also the local peasants with whom they forged links as they prepared to overthrow the government. They attempted to repeat the exercise elsewhere, including in Bolivia, where Guevara met his death in 1967. His "revolutionary medicine", urging a new generation of poor Cuban students to train as doctors and return to rural areas to fight disease, helped directly to save many lives.
After the revolution, inspired by the state-controlled, centralised Soviet system, the new leaders established a network of polyclinics emphasising preventive care across the country. They also began providing allies with medical help alongside military support. In 1963, Cuba went to the aid of Ben Bella's regime in Algeria, sending 58 doctors and nurses to accompany soldiers in border skirmishes with Morocco, and bringing the injured back to Cuba for free treatment. Two years later, Guevara joined local insurgents trying to overthrow Moise Tshombe in Zaire, and while there helped launch one of Africa's first mass immunisation campaigns.
More than a dozen missions followed in subsequent years, from Angola to Zimbabwe. The medical support was often more successful and enduring than the military assistance. It forged long-term links with Havana, which more recently has conducted clinical trials and supplied medicines to the continent as its own fledgling pharmaceutical industry grows.
Cuba's tough border screening for HIV, introduced in the mid-1980s, also provided an early warning system to its foreign allies. In autumn 1986, Castro pulled Uganda's President Yoweri Museveni to one side at a conference of non-aligned nations to warn him that 18 of the 60 top Ugandan officers sent to Cuba for training had tested positive for HIV, suggesting the epidemic would kill more of his people than conflict. The alert kickstarted one of Africa's earliest and most aggressive Aids prevention programmes.
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Dr Mayda Guerra Chang appears firmly rooted in her community clinic in western Havana, but like many of her colleagues, her most formative experiences took place abroad. In 1990, just after graduating, she was one of 300 Cubans to travel to Zambia, many assigned to tiny villages to help build the health system under President Kenneth Kaunda. "I wanted to go to Africa because of the conditions: you never face health problems like that here," she says. "The local doctors had quit to go into the private sector or to other countries. The hospital I worked in had a good building, but it was empty of staff and there was not much equipment. There were no syringes and very few drugs. You had to do your best and pray."
Her experience was typical of Cuban medical solidarity after the initial revolutionary era. As Africa's health systems crumbled through decolonisation, underfunding, poor management and the emigration of tens of thousands of local doctors and nurses to Europe, Australia and North America, Cubans helped to fill the growing void. The fiercest clashes Guerra Chang faced were not military but ideological – cheap Cuban specialists were viewed suspiciously by local doctors who were often practising privately or agitating for higher public-sector wages. She recalls the irritation of Zambians striking for pay rises. "They said the Cubans were strike-breakers, and we were not helping them. I understood, but when you are working on the health of people you prefer not to strike."
Such resentment towards Cuban doctors abroad is particularly vocal in Latin America, where Havana has co-ordinated a growing number of medical secondments over the past few years, capitalising on the proximity, common language and growing political solidarity of the region. Local medical associations have complained that their counterparts lack the requisite skills and fail to co-ordinate with their members' activities. They also see the Cubans as a threat to their own jobs.
Dr Israel Nolasco Cruzata laughs off such criticism. Now practising back in Havana, he spent three months in Honduras, and then five years in Venezuela, which has become the largest single destination for Cuban medical staff – up to 30,000 are currently employed there. "Cuban doctors go to the worst places, where there are the worst problems," he says, stroking his pencil moustache. "I worked with people who had never seen a doctor, and I came back a better person. Local doctors looked at patients just for money. We are taught that you are first of all the friend of the patient. Health is not just something for us. We know about it and want to give it to the rest of the world. If I am asked to go again, I will."
There is a more direct incentive for the Cuban doctors to work abroad, too. They earn up to 10 times their local salary, and have the prospect of better housing and jobs on their return. Most of their money is held in escrow until they come back, and they are expected to visit once a year. Their families usually have to stay in Cuba. Yet, in spite of the penalties, several thousand Cuban medics have defected over the years, complaining about repressive supervision, being treated with suspicion while on a posting, or being put under pressure to speak out as political advocates. For most, however, fleeing is not an option.
Meanwhile, medical services are one of Cuba's most important sources of foreign currency. Most nations provide a modest return: the host government pays for travel, accommodation and a stipend of up to $200 a month per doctor. Richer countries – from Angola after it found oil in the 1960s, to South Africa under the ANC – contribute more. Cuba has even begun offering medical support for commercial fees in countries such as Qatar. And no partner is more important than Venezuela. The secondments enabled President Hugo Chávez to point to a rapid rise in the numbers of medical specialists when seeking to justify his social revolution. The financial terms are confidential, but the quid pro quo includes heavily subsidised oil supplies to Cuba. As Fidel Castro once put it: "We provide doctors to Venezuela on a humanitarian basis, and Venezuela provides us with oil on a humanitarian basis." But some Cubans complain that foreign assignments have stretched doctors at home too thinly between poorly equipped clinics.
John Kirk, a Canadian-based academic, concedes that money and diplomatic influence are among the benefits of the programme to the country. But his recent book, Cuban Medical Internationalism, concludes that the motives are far more complex. "Fidel Castro [was] just obsessed with public health," he says. "There's a very different approach to the liberal western model – a belief that Cuba needs to share its wealth. As the saying goes, Cubans either don't quite reach their goals or – as with the doctors – they go way over the top."
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In December 2008, in the final days of the Bush presidency, health secretary Michael Leavitt gave a speech at the Centre for Strategic and International Studies in Washington, DC. His theme was the challenges for global health, but one of his main targets was not malaria, Aids or cancer, but Cuba. "Health is a legitimiser of governments and of ideologies," he said. "Health also legitimises revolutionary socialists. Fidel Castro has very little hard power on that small island of Cuba, but he has become a master at the use of health diplomacy to create soft power.
"The doctors become trusted members of the community and they become quite influential political organisers among the poor and the disadvantaged. They have stature ... They become politically active. They feed the discontent and then they're given a small salary and Castro even makes some money on the deal. It's actually a very clever strategy. I suggest to you that it's not a good thing for the United States to have central American governments dependent upon Cuba… Healthcare is a litmus test for these governments on whether they are legitimate and whether they are effective. Using healthcare to discredit democracy and the ideologies of liberty is a tactic that is right out of the insurrectionist's handbook."
He was not alone in his views. In 2001, the US and other countries dismissed a Cuban offer to staff an ambitious international programme to treat HIV, in exchange for funding and supplies of drugs. In 2006, Washington launched an accelerated asylum programme for Cuban doctors, encouraging them to defect while serving abroad. At least 2,000 have. While Barack Obama has made more positive remarks about Cuba's health diplomacy, the US embargo and asylum system remain in place.
However, Elam has set up a shorter-term migration programme in the opposite direction, bringing thousands of foreigners into Cuba to train as doctors. Because it does not charge its students, it has bypassed the long-standing US embargo and attracted some applicants from the least expected places. Damian Suarez, who grew up in New Jersey, is one example. He says he preferred to study medicine in Cuba rather than follow in the footsteps of his brother, who is serving in the US army in Afghanistan. "We get to study on the beach, go to school and save lives," he says.
Ian Fabian, a lanky, bearded student from New York also studying at Elam, agrees: "This is a project for the world. The US is a nation without universal access to healthcare although it spends twice as much per head on health as most other countries. I heard about Fidel's speech in Harlem, [in which] he talked about third-world conditions in a first-world country."
Fabian grew up in the poor Hispanic neighbourhood of Washington Heights in New York, and says he would never have been able to fund his way through US medical school. He now plans to fulfil his dream of working as a doctor in a public hospital in his home neighbourhood. "Here [in Cuba] they train you, pay your expenses and don't even ask you for a promise with a handshake in return. They hope your ethics as a professional mean you will go back to serve your community."
Andrew Jack is the FT's pharmaceuticals correspondent. His last piece for the FT Weekend Magazine was about the "blockbuster" drug Lipitor, whose patent expires in 2011. Read it at www.ft.com/lipitor
Asylum: no panacea
Cuban doctors do defect to the US – but often can't practise
From his modest office in a community centre in the western suburbs of Miami, Julio Alfonso is helping recreate some of the more positive elements of Cuba's medical system – but with a very different ideology. A decade ago, he sought asylum in the US, after more than a year's imprisonment in Cuba and a ban from practising medicine due his opposition, as a Catholic, to conducting abortions; his reluctance to serve abroad in Angola; and his criticism of the regime.
He calls the Cuban health system "the biggest slave army in history", citing the low salaries the doctors earn compared with the foreign currency they bring in for their government. And he says many of his peers worry over being expected to give speeches supporting the regime while on assignment.
Alfonso remembers vividly the day in September 2006 when the US eased refugee status for Cuban medical staff. But while he has since gained the right to work in the US, language barriers and the burden of retraining mean he cannot qualify here as a doctor. It's a fate shared by almost all of the 2,000-plus doctors who have defected to the US since.
After spells as a supermarket worker, a dock worker and a medical technician, Alfonso is now helping manage a medical clinic for the uninsured and those on low incomes in Miami. He says it is "criminal" that so many people have such difficulty gaining access to medical care in the US.
Now, sipping sweet Cuban coffee, he takes a phone call from a contact in Nicaragua seeking help for Cubans who have sought asylum there. Then he rings Washington to lobby on behalf of a doctor in his office who defected from Paraguay and is trying to reunite with his wife, a Cuban who fled while on assignment in Ecuador.
Alfonso would like to see greater US support for Cuban émigré doctors. As is, he spends his time mirroring Cuba's medical diplomacy – but on a more modest scale. He co-ordinated the dispatch of a small contingent of his peers to Haiti last year, and again after the earthquake in January this year. He has also sent money and medicines to one doctor in Cuba who was working independently until his recent arrest and imprisonment.