Cuban Medical Diplomacy: When the Left Has Got It Right
As an addendum to Dr. Feinsilver's article on Cuba's Medical Diplomacy, please note that in August the Bush
Administration announced its intention to lure to the U.S. some of the 15 to 20 thousand doctors now providing medical
aid mainly in Venezuela and Bolivia by making it easier for Cuban doctors participating in the island's medical program
abroad to gain refugee status in the U.S. In her report, COHA Senior Research Fellow Julie Feinsilver analyzes the
multiple aspects of Cuban medical diplomacy. A version of this article originally appeared in Foreign Affairs en Español
Vol. 6 (Octubre-Diciembre 2006), pp. 81-94.
The Cuban Threat: Medical Diplomacy
Living in a hostile neighborhood led Fidel to look for allies elsewhere. Part of this process has included the conduct
of medical diplomacy, which is the collaboration between countries to improve relations and simultaneously produce
health benefits. Medical diplomacy has been a cornerstone of Cuban foreign policy and its foreign aid strategy since
shortly after the triumph of the 1959 revolution. Despite Cuba’s own economic difficulties and the exodus of half of its
doctors, Cuba began conducting medical diplomacy in 1960 by sending a medical team to Chile to provide disaster relief
aid after an earthquake. Three years later, and with the US embargo in place, Cuba began its first long-term medical
diplomacy initiative by sending a group of fifty-six doctors and other health workers to provide aid in Algeria on a
fourteen-month assignment. Since then, Cuba has provided medical assistance to scores of developing countries throughout
the world both on a long-term basis and for short-term emergencies.
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.
Statistical Registers of the Central Medical Cooperation Units, 2005 Statistical Yearbook of the Cuban Ministry of
Public Health
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: Cuban Health Department 2005
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.
Ends