When the Ebola outbreak first spiralled into an
international crisis, the country that dispatched the largest contingent of
medical personnel to help was not a major western power, but Cuba, a small
island nation of 11 million with a GDP of $6,051 per capita[1]. There are hundreds of Cuban medical staff now
in Sierra Leone, Liberia and Guinea - more than from any other nation. In contrast, many western countries have
seemed “more focused on stopping the epidemic at their borders than actually stemming it in West Africa.”
For Cuba to be playing such a major role in the medical
response to the crisis is not unprecedented.
Cuba currently has around 50,000 medical workers in 66 countries around
the world and has more health workers deployed abroad than any of the G8
nations. Fidel Castro’s newly formed
government first dispatched medical aid abroad in 1960, following an earthquake
in Chile. Many more missions in numerous countries followed over the subsequent decades.
The country’s current dedication to what has been termed ‘medical
internationalism’ originated in the aftermath of Hurricanes George and Mitch,
which devastated the Caribbean in 1998.
The Cuban government vowed to train one doctor for every life lost in
the storms. To achieve this aim they established
the Latin American Medical School: ELAM.
Initially it was free for all students to attend (Raoul Castro’s reforms
since taking power from his brother Fidel in 2008 have included charging North
American students to attend ELAM) and has subsequently trained over 33,000
students from 76 different countries, who return home to practice, usually
amongst the world’s poorest people.
After the Haiti Earthquake in 2010, it was Cuba that provided
the highest number of health workers, many of whom had been there since the
1998 storms. Cuba also sent 2,250 doctors
to treat survivors of the Kashmir Earthquake in 2005. But Cuba does not limit its offers of
assistance to poorer countires. Within 3
days of Hurricane Katrina hitting New Orleans in 2005, Cuba had assembled 1,100
doctors and nurses and 24 tonnes of medicines, ready to fly to the US, but the Bush
government did not even acknowledge the offer.
Although the Cuban Henry Reeve Brigade (named after a US
volunteer in Cuba’s war of independence against Spain of 1868-1878) is trained
in disaster relief medicine, Cuba also commits to long-term projects. They dislike the paternalistic term ‘medical
aid’ and instead prefer ‘medical cooperation’ or ‘collaboration’. When Cubans are sent to disaster areas, they
are there for the long haul, usually working in the affected area for two
years, and will be replaced by more Cubans should the need persist.
The importance of a robust healthcare system has been a key
Cuban policy since Castro’s rebels overthrew Batista in the Revolution of
1959. Ernesto ‘Che’ Guevara, Fidel
Castro’s right hand man and himself an outsider who came to the aid of a
country in need, had qualified as a doctor back home in Argentina before
turning to life as a revolutionary. Both
he and Castro believed that unrestricted access to medical care was a basic
human right and it was therefore enshrined in the Cuban constitution. Despite the fact that almost half of Cuba’s
doctors had fled from the communist regime by 1961, Che’s ‘revolutionary
medicine’ encouraged a new generation of poor Cubans to train as doctors and
return to those poor areas to practice.
The emphasis placed on good quality medical care still
persists. In Cuba, doctors visit all
their patients at least once a year, regardless of whether they are ill or
not. This model has been in place since
the revolution – the cornerstone of Cuba’s medical system is that prevention is
better than cure. This, alongside a
comprehensive programme of vaccinations, has led to a significant reduction in
the infectious diseases that blight Cuba’s Caribbean neighbours. The net result is a mortality rate similar to
that enjoyed by developed nations: “as Cubans joke, they live like the poor but die like the rich.” In addition, “Cuba produces some 80 per cent of its own medical products, which are sold at a fraction of the price they would cost elsewhere.”
However, alongside these admirable principles lie some uncomfortable truths. The average Cuban doctor’s salary is only $25 a month and many doctors trained for free in Cuba defect once they are sent abroad. The Bush Administration was particularly keen on promoting this and set up a special programme in 2006, specifically targeting Cuban doctors and encouraging them to defect to the US. Until January this year, when the high price of exit visas for Cubans was dropped, the cost of leaving the country prevented the ‘brain drain’ suffered by other poorer nations. Since January, there has been a marked increase in the number of Cubans exiting the country legally and it remains to be seen what impact this will have on Cuban medical care. What is certain, however, is that medical internationalism has had an effect on Cuba’s national healthcare system, with waiting times for GPs increasing. Yet although approximately 20% of Cuban doctors are working abroad, “the ratio of doctor to patients in Cuba is still probably the best in the world.”[2]
Prior to this year’s Ebola outbreak, Cuba had been a
longstanding friend of many African nations.
In 1963, Cuban doctors and nurses accompanied Algerian soldiers fighting
on the border with Morocco and the injured were brought back to Cuba for free
treatment. In 1965, Che himself went to
fight alongside local insurgents in Zaire (now the Democratic Republic of
Congo) and whilst there “helped launch one of Africa’s first mass immunisation campaigns." Many more operations took place over the
following decade, but it was the medical support, rather than the military,
which was more effective and ended up forging the stronger links. In the 1970s, when many emerging nations were experimenting
with socialism and aligning themselves with communist states who opposed their
former colonial masters, ties deepened between Cuba and Africa. When Sierra Leone president Ernest Bai Koroma
welcomed the first Cuban delegation in the capital Freetown last month, he announced
“this is a friendship that we have experienced since the 1970s and today you have demonstrated that you are a great friend of the country.”
Why is Cuba so committed to medical
collaboration? First and foremost, it is Cuba’s
main export. The largest cohort of Cuban
medical personnel working abroad are in Hugo Chavez’s Venezuela, in exchange for
around 100,000 barrels of oil a day at preferential prices. The Cuban government
is now specifically looking to expand their collaboration into wealthier
countries. Secondly, medical internationalism is unquestionably a
form of soft power for Cuba, winning the country influence with potentially hostile
governments and consolidating support from other smaller nations. Just last month, 188 members of the United
Nations voted for the 23rd time to condemn the US embargo against
Cuba, first imposed by President Kennedy in the 1960s. There are signs that the US may be ready to
take a more open approach to Cuba’s medical internationalism, and, much to the consternation of the Republicans, the Obama administration has sent officials
to meet with the Cubans to discuss a joint approach to the Ebola crisis.
It is hoped that this combined response to Ebola may pave the way for an ending
of the embargo.
There are those who argue that Cuba’s medical
internationalism does little to negate the serious human rights abuses taking
place within its own borders. There is
widespread repression of civil liberties in Cuba, especially with regards to
political dissidents and journalists, with all media being heavily
censored. Though capital punishment was officially
ended in 2003, there remain complaints of unfair trials, unjust sentences and
torture in Cuban prisons. Even within
the revered healthcare system there is no right to privacy, patients do not
have the right to refuse treatment and doctors are expected to report on the
political leanings of their patients. The favourable international view of Cuban
healthcare is doubtless coloured by suppression of dissenting views. The fact that such a small nation has made
such a disproportionate contribution to the wellbeing of some of the world’s
poorest nations is commendable and there is no doubt that Cuban medical
personnel working abroad have significantly improved the health of millions
around the world; it is only a shame that it should come at such a high cost to
the freedoms of the Cuban people.
[1] To
put that in context, the GDP of the USA is $53,143 per capita.
[2]
There are 6.7 GPs per 1,000 people in Cuba – there are 2.4 per 1,000 people in
the US and in Canada - http://www.counterpunch.org/2012/12/14/medical-internationalism-in-cuba/
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