Abstract
This article explores Cuba’s health assistance and support for other countries. It explores the rationale and motivations for Cuba’s internationalism in health. It then details the various aspects of its health interventions, including emergency relief, strengthening of health systems, treatment programs, training of health professionals, engagement in multilateral cooperation, and biotechnology. The article analyzes the benefits of Cuba’s health internationalism for Cuba and for others. It also explores potential adverse consequences and criticisms of Cuba’s approach. The article concludes by noting that Cuba has been ahead of the game in integrating foreign policy and health policy and that its experience may hold lessons for other countries seeking to develop global health strategies.
Cuba’s involvement in the international effort to control the West African Ebola outbreak of 2014–2016 was warmly applauded by Margaret Chan, then director-general of the World Health Organization (WHO).1,2 More surprising, given the enmity between the United States and Cuba, was praise from senior figures in the U.S. administration, including President Obama. Partly due to a new spirit of cooperation between the 2 countries – symbolized by the public handshake between Barack Obama and Raúl Castro at Nelson Mandela’s memorial service in December 2013 – Cuba’s participation received positive media coverage in the West.
However, the Western media had largely ignored Cuba’s international health activities during the previous half century. The Cuban government estimated that between May 1960 and May 2016, 325,000 health professionals had worked in 158 countries. 3 In May 2016 alone, 55,000 were working in 67 countries, including 25,000 doctors. The majority of these health workers were based in Latin America and the Caribbean, with others in Africa, Europe, the Middle East, Asia, and the Pacific. 3 An estimated one in 5 Cuban doctors works overseas at any point in time. 4
This article explores various aspects of Cuba’s health internationalism. It is based on research funded by the British Academy between 2012 and 2015. The project involved an initial review of the existing literature, followed by primary research: 25 semi-structured interviews with key informants (including policy actors and observers from Cuba, Europe, and the Americas). The authors visited Cuba twice, met with Cuban policy actors and academics, and attended an international conference in Havana, which focused on learning from Cuba’s health achievements. These visits also included opportunities to see health facilities and meet frontline health workers (some of whom had served on overseas health missions). This research project was approved by the Leicester Business School, De Montfort University. It is compliant with the Social Research Association Guidelines. All participants received prior information about the research and indicated their consent.
Background and Context
The Cuban revolution embodied ideas of solidarity, populism, and humanism, both domestically and internationally. 5 Fidel Castro wanted to make Cuba a world medical power. 6 The protection of population health and the provision of health services were seen as a means of liberating people and building solidarity across nations, especially in countries lacking the means to address basic human needs such as food, shelter, health, and education.
Huish 7 argues that solidarity is the key to understanding Cuba’s international cooperation in health. However, Cuban internationalism in health has also been shaped by pragmatic motives. Medical diplomacy, a cornerstone of Cuban foreign policy since the revolution, has generated symbolic capital in terms of international prestige, goodwill, and influence.6,8–10 This has yielded a form of soft power 11 exercised through promoting values, mutual agreement, cooperation, exchange, and the provision of free or subsidized goods and services, which has been particularly useful in helping Cuba build alliances with other countries.
Cuba’s health internationalism has also been driven by economic circumstances. The U.S. embargo led Cuba to enter into alliances to ensure access to goods and resources. Initially, the Communist Eastern Bloc provided this lifeline. But the collapse of Soviet Union, coupled with even stronger U.S. sanctions, devastated the Cuban economy. Between 1989 and 1993, Cuba lost 85% of its foreign trade, and GDP fell by more than a third. 12 The Cuban government introduced emergency measures in what became known as the Special Period. But health services were protected rather than cut, and there was additional investment in biotechnology, inward health tourism, and the export of professional services, especially health services. Consequently, Cuba strengthened its reputation in these areas, and foreign earnings from them grew, strengthening its economy. 13
The Scope of Cuban Medical Internationalism
Disaster and Emergency Assistance
Cuba’s international health activities grew out of ad hoc missions to disaster areas.14,15 The first overseas health mission was in 1960, when a medical team was sent to Chile following an earthquake. Since then, many more countries have benefited from Cuban health missions, including Peru (earthquakes, 1970 and 2007), El Salvador (Dengue fever outbreak, 2000; earthquake, 2001), Nicaragua (earthquake, 1972; volcanic eruption, 1992; intense rains 1991), Guatemala (hurricanes, 1998 and 2005), Haiti (hurricane 1998; earthquake, 2010), Honduras (hurricanes, 1974 and 1998; intense rains, 1999; earthquake, 2009), Venezuela (torrential rains and mudslides, 1999), Indonesia and Sri Lanka (tsunami, 2004), and Kashmir (earthquake, 2005).
In 2005, the Cubans formed the Henry Reeve International Medical Brigade (named after a U.S. volunteer who died fighting for Cuban independence in 1876). This was a means of improving coordination of international emergency responses by working with other providers of medical aid and relief. In May 2017, the Henry Reeve Brigade was awarded the Lee Jong-wook Memorial Prize for Public Health at a World Health Assembly ceremony. This prestigious award recognized the brigade’s work in helping over 3.5 million people in 21 countries affected by disasters and epidemics.
Cuban medical aid focuses on building sustainable systems rather than short-term interventions. Cubans tend to live and work within the communities they are supporting and, as well as providing health services, seek to tackle social and environmental determinants of health. 16 Their brand of emergency assistance strives to create an infrastructure to improve and protect health in the longer term.
For example, following the devastating impact of Hurricane Georges in 1998, more than 6,000 Cuban doctors and health care professionals served in Haiti during the next 8 years. 17 In addition, around 1,000 Haitian nationals were trained at the Latin American Medical School (ELAM – discussed later in this article). In this period, it is estimated that Cuban health care workers received more than 10 million patient visits, undertook more than 4 million visits to patients, attended 86,000 births, and administered almost 900,000 vaccinations. Cuban doctors saved an estimated 200,000 lives through emergency care alone. Haiti’s health indicators improved enormously. Infant and child mortality more than halved between 1999 and 2007, maternal mortality almost halved, and life expectancy increased by 7 years. 17 Cuba’s assistance to Haiti has continued. During an earthquake in 2010, 350 Cuban health professionals were in the country and were joined by many more. By 2016, 567 Cuban health professionals, including 125 doctors, were still working there. 3
Strengthening Health Care Systems
Cuba has worked with many countries to help restructure and improve their health care systems. In the late 1990s, these “structural cooperation” programs were reorganized into Comprehensive Health Programmes. These were introduced in Latin American countries, the Caribbean, Africa, and subsequently in some Asian and Pacific countries.8,14 Comprehensive Health Programmes, which focus on establishing highly integrated primary health services, were acknowledged by several of our interviewees as an important means of strengthening the health care systems of host countries.
In some cases, Cuban support is financed by the host countries themselves (or by third parties, such as other countries or international agencies). Gabrielle, writing in 2010, found that since 1960 only a minority (12%) of Cuba’s health personnel serving abroad had done so on the basis of “foreign exchange generating modalities.” 13 However, since the early 2000s Cuba has placed much greater emphasis on income generation. Indeed, large-scale programs, such as those discussed later, have tended to generate income or other valuable resources. Nonetheless, in 2016, a substantial proportion of countries (44%) receiving medical services from Cuba were still not being charged for them. 18
In 2003, Cuban health workers began to establish health services in Venezuela, targeting communities with poor access to care. This program, Misión Barrio Adentro, was part of a deal known as “Oil for Doctors.” Cuba received subsidized Venezuelan oil in exchange for its medical assistance (though in practice the arrangement was more complex and covered a range of collaborative programs and projects). Misión Barrio Adentro involved more than 30,000 Cuban health workers (doctors, nurses, optometrists, therapists, dentists, and technicians) in the establishment of a free nationwide health care system.19–21 Under first phase of Barrio Adentro, 17 million people had access to health care, compared with 3.5 million in the conventional system. 20 Population health improved, and health inequalities narrowed. 22 Further phases of Barrio Adentro involved new hospital facilities, investment in specialist services, and training of health workers. 20 Although the major health gains yielded were undermined by the socioeconomic and political crisis that has since engulfed Venezuela, Barrio Adentro showed what could be achieved with Cuban expertise and assistance in a relatively short space of time. Moreover, despite the problems facing Venezuela in recent years, substantial numbers of Cuban health professionals have continued to work there (28,351 in 2016, including 8,987 doctors) 3 in difficult and dangerous conditions. The situation would undoubtedly be even worse in their absence.
In 2013, the Brazilian government launched Mais Médicos (“More Doctors”), a new program to improve access to health care, in collaboration with Cuba and the Pan American Health Organization (PAHO). Over 11,000 Cuban medical professionals, mainly doctors, went to work in poor or remote areas, including deprived urban areas and special indigenous districts. Around four-fifths of the doctors involved in the program were Cubans, paid for by the Brazilian government. 23 The program was acknowledged as improving health system capacity and extending access to health services to deprived populations. 23 Although Brazil tried to involve more of its own homegrown doctors in the program, 10,987 Cuban doctors were still working there in 2016, when the program was extended. 3
However, following the fall of the Rouseff government in the same year, an interim administration was formed by Michel Temer. His government adopted a Conservative approach, backtracking on commitments to universal health care and seeking to cut back Mais Médicos by limiting the participation of foreign doctors (including Cubans). The Temer government was particularly hostile to Cuba, and future cooperation on health matters looked in doubt. Nonetheless, Mais Médicos was continued with Cuban involvement. Although the number of Cuban doctors involved in the program has fallen by about a quarter since 2015, as a result of gradual substitution by Brazilian doctors, more than 8,000 remain (representing just under half of the total number of doctors engaged in the program). 24
Many other examples exist of Cuban health professionals generating income from their work. For over 2 decades, the government of South Africa has paid for Cuban doctors to work in its health care system. This arrangement continues, with more than 300 doctors currently working there. 3 South Africa also pays Cuba to educate and train some of its own medical workforce, discussed below. Since 2009, Portugal has hired Cuban doctors to fill a gap in the ranks of family doctors (50 were employed there in 2016). 3 Qatar, one of the wealthiest countries in the world, also pays Cuba to provide health care. In 2012, a new hospital was built in Dukhan, staffed by 400 Cuban health professionals. Other countries in the Middle East have also employed Cuban doctors, including Saudi Arabia, Kuwait, and Bahrain.
Treatment Programs
Cuba has also undertaken specific treatment programs overseas. Operation Miracle (Operación Milagro) was launched in 2004 to provide free eyesight-restoring operations for Venezuelans. 25 With additional funding from the Venezuelan government, Operation Miracle was subsequently rolled out to more than 30 countries, undertaking 1.8 million operations by 2010 (and 3.9 million by 2016). 26 These included countries in the Caribbean, Central and South America, and Africa. Operation Miracle has huge implications for the quality of life, communication, and education, as well as for the health of those treated. Several of our interviewees mentioned it, not just as an example of a successful humanitarian health initiative, but also as a lesson to developing countries about what can be achieved through South-South collaboration.
Cuba also treated victims of the Chernobyl disaster (more than 26,000 people, mainly children), 10 mostly from the Ukraine. Treatment included specialist endocrinology, gastroenterology, and dermatology care. This was provided free until 2011. Allegedly, Ukraine had agreed to pay Cuba to continue these services, but payment was not forthcoming, so the program was discontinued.
In addition to these programs, people from around the world have sought treatment in Cuba, paying privately (in some cases funded by their government). It is difficult to obtain accurate figures on the number of “health tourists” treated in Cuba, or in any country, given the lack of an agreed-on definition or standard measure. 27 Respected authorities cite annual figures of between 20,000 and 25,000 patients a year, yielding between US$30 million and $40 million a year in income.28,29 However, any figures must be treated with caution: other estimates range from around 3,000 to 200,000 people per annum. 27
Cuba provides a range of health services for foreign nationals, including surgery (particularly eye, orthopedic, and plastic surgery), dental care, and cancer treatment. Rehabilitation services are provided for people with long-term neurological illnesses and acute injuries. Other specialties include cardiology, dermatology, and addiction treatments. The costs of treatment are relatively low compared to private medicine in Western countries. Tourists are treated in separate clinics, which are generally of a higher standard than those catering for the local population and have full access to the latest drugs. The Cuban government has tried to expand private treatment for foreign nationals and has established specific organizations to arrange these services. Some within Cuba are concerned that this policy has created a 2-tier system, 30 but this is often justified by arguments that resources generated can strengthen health services for ordinary Cubans.
Training of Health Workers
Cuba has one of the highest number of doctors per patient in the world: 7.52 per 1,000 people, more than double the OECD average. 31 Cuban doctors are trained to serve overseas and are experienced in working where resources are scarce – as in emergency situations and among poor and disadvantaged communities. Their training focuses on primary care, prevention, public health interventions, community-based services, social and environmental conditions, and harnessing of limited resources. As one of our informants noted, the focus on prevention, primary care, and working with communities is ideally suited to countries in desperate need. Our interviewees perceived Cuban health workers as being particularly suited to emergency and disaster situations and working with poor and disadvantaged communities. However, the utility of their approach is not confined to poorer countries. As one informant commented: “Cuba is . . . seen as training a particular type of health worker/doctor that is useful to developing countries, and also to developed countries.” Furthermore, while working overseas, Cuban doctors are also credited with providing on-the-job training to local health workers and often passing on valuable skills and knowledge. 32
In addition, Cuba provides free medical education and training for foreign students. The Latin American Medical School (ELAM) was established in 1999 solely for this purpose. In August 2017, approximately 4,500 students were studying there, drawn from 112 nations. Since the program began, 28,500 students from 103 countries have graduated from ELAM. 33 Since 2001 these ranks have included 170 students from the United States, drawn from poorer communities.
Scholarships from the Cuban government provide funding for students, although wealthier countries now pay for their students. There is positive discrimination in favor of women, ethnic minorities, and students from poorer families and communities. Training focuses strongly on primary care, prevention, and community-based interventions and is geared to meeting the health needs of poorer communities.4,34 Graduates are expected to serve these communities once qualified.34,35 In 2014, it was reported that two-thirds of U.S. ELAM graduates were working in deprived areas. 15 However, graduates cannot be forced to work in such areas or in the public sector. 7 Indeed, some of our informants indicated that students had expressed an interest in working in private practice at some future time.
There has been some acknowledgement of ELAM’s contribution to the supply of doctors and health system capacity worldwide, especially to poorer countries.10,36–38 This has been characterized as “brain gain” – in contrast to the usual “brain drain” of health professionals from developing to developed countries. 39 ELAM has been praised because it aims to educate medical professionals for public service in disadvantaged communities rather than for highly paid private practice. Its positive discrimination in favor of female candidates, ethnic minorities, and recruits from poor communities has also been acknowledged. 35 Another advantage of Cuban medical education is its focus on community-based primary care and prevention, 40 seen as the right direction for health care reform worldwide. 41 All these positive attributes were identified by our informants.
Cuba has established training programs and facilities in many other countries. One of the largest was in the Barrio Adentro program, where Cuban doctors provided training to indigenous medical students. 19 Cuba has established medical training establishments in Africa (for example, Ethiopia, Uganda, Ghana, The Gambia, Equatorial Guinea, Guinea-Bissau), Central and South America and the Caribbean (Haiti, Guyana), the Middle East (Yemen), and South East Asia (East Timor). 16
Cuban medical training has been criticized in some quarters. Cuban-trained graduates often face obstacles in being accepted by their home country regulatory systems and professional bodies, a point raised by some of our interviewees. Although defenders of Cuban medical education identify unwarranted bias and ignorance as factors in this problem, critics blame the quality of Cuban medical training. For example, leading South African doctors have argued that Cuban medical training programs do not sufficiently prepare graduates for practice,42,43 arguing that the burden of illness and disease in their country is very different from Cuba. In particular, they question Cuban-trained graduates’ ability to treat chronic illnesses and violent injuries.
There is certainly a genuine mismatch in some countries (including South Africa) between their weak primary care systems and the strong primary care emphasis of Cuban medical training. This can lead to Cuban-trained students lacking experience and skills needed by the host country’s health system. 34 Even so, Cuban-trained doctors are often very well qualified for delivering health and care services, especially when they are working in poor and disadvantaged communities. They are also likely to contribute considerably to health care systems which are trying to reorient themselves toward primary care, community-based services, and prevention.
Other criticisms center on the experience of ELAM students and the difficulties they face. Students are far from home, live on a basic allowance, and often lack basic amenities. 34 Many are learning in a foreign language (Spanish), which can further add to stress. In the particular case of South African students, there have been well-publicized reports of stress-related illness, alcohol misuse, poor discipline, and withdrawal from the training program. 44 Students have protested about poor living conditions, food rations, and low stipends. 34 Such problems were corroborated by 2 of our informants, who observed that a substantial number of South African students had been admonished (and some sent back to their home country) for poor behavior, low attendance, and heavy drinking.
Multilateral Cooperation and Relief
It would be wrong to see Cuban medical internationalism as a purely unilateral approach. Cuba is increasingly part of bilateral and multilateral health initiatives. As one of our interviewees commented: “Cuba is an important health provider in the international health agency network.” Some multilateral work is linked to the Bolivarian Alliance for the Peoples of Our America (ALBA) and Peoples’ Trade Treaty (an alternative to the Free Trade Area of the Americas proposed by the United States). ALBA originally included only Cuba and Venezuela but later expanded to include Bolivia and Nicaragua. It currently has 10 member states. The key aims of ALBA were to establish a regional economic bloc and to establish greater cooperation and solidarity between countries. Operation Milagro was delivered through such cooperation, with Cuban medical expertise and Venezuelan funding, and a similar model was used to provide comprehensive health programs, for example, in Bolivia. 45
Other countries have also contributed financial assistance for Cuban health services in less-developed countries. 46 For example, Switzerland, Libya, South Africa, and Nigeria helped to fund Cuban work in Mali. Germany, Libya, and Nigeria financed Cuban health interventions in Niger. France, Japan, Brazil, Venezuela, and Norway helped to fund Cuban health workers efforts in Haiti.
In practice, Cuban health work overseas is funded by a mix of countries and often includes international agencies. Several of our interviewees commented on the important role of international agencies, such as WHO and its regional offices (notably, PAHO) and UNICEF, in bringing Cuba into alliances to help other countries. Cuba has increasingly received aid from U.N. agencies to enable the provision of medical relief.
For example, WHO paid Cuban health workers for their work in the West African Ebola crisis. While many countries provided funds and equipment, they were reluctant to commit personnel. In contrast, Cuba sent 256 health professionals to Liberia, Guinea, and Sierra Leone. The Cuban health workers were paid more than they would have received at home (in line with other overseas missions). But this cannot have compensated for the risks involved (2 Cubans died from malaria, and 1 contracted Ebola but survived). Ironically, the U.S. embargo delayed the payments to Cuban staff, and special permission was needed to transfer the funds. 47
Furthermore, Cuba’s involvement in Brazil’s Mais Médicos program was facilitated by PAHO, which brokered the agreement and provided logistical support, administrative support, training, monitoring, and evaluation. PAHO also disseminated the lessons of the program to other countries in the region. As noted, the Cuban government initially supplied the majority of the doctors to the program while the Brazilian government paid the Cuban government for their services.
Biotechnology and Health Industries
The Cuban state has invested heavily in biomedical science and technology research and development, especially pharmaceuticals.10,48,49 This investment, which began in the 1980s and was prioritized during the Special Period, has paid off. Cuba’s biotechnology industry expanded considerably, and the country has one of the fastest growing pharmaceutical industries worldwide. 50 It currently involves more than 30 institutions employing 22,000 people. Cuba produces 65% of the medicines it needs for its own population. 51 In 2013, overseas sales of pharmaceuticals stood at US$359 million, 52 representing almost 12% of Cuban exports. 53 More recent estimates, however, indicate a significant decline in exports (down to US$42 million in 2017, less than 5% of total exports). 52 This appears to be linked to the economic crisis in Venezuela and a consequential fall in oil supplies to Cuba, which has had a negative effect on the latter’s economy.
The Cuban pharmaceutical industry has made a number of significant innovations, including a meningitis B vaccine (a world first in 1988), an innovative hepatitis B vaccine, cancer drugs (including a pioneering lung cancer vaccine), and a new treatment for diabetic foot ulcers that reduces the risk of amputations. 54 Cuba produces more than 30 different vaccines, 33 anti-cancer drugs, 18 cardiovascular drugs, and 7 drugs to treat other diseases. It exports to 50 (mainly Latin American) countries. Cuba is increasingly working jointly on the development of new drugs with other countries, including Brazil, China, Canada, the United Kingdom, and France.49,55 It has even worked with the United States. CimaVax, the world’s first lung cancer vaccine, was developed in Cuba and is currently the subject of clinical trials in European Union countries, Japan, and the United States (where the Food and Drug Administration authorized the Roswell Park Cancer Institute in New York to undertake a trial). 56 Cuba has also collaborated with other countries on the manufacture and production of drugs, working with China, Malaysia, Brazil, South Africa, Mexico, and India, among others.10,51,55
Cuban research and development strategy deliberately prioritizes drugs to prevent and treat illnesses found disproportionately in poor countries. For example, it has produced affordable vaccines to combat cholera and typhoid and low-cost generic drugs for HIV/AIDs. 55 Drug development and production is more closely aligned with both domestic health needs and those of poorer populations overseas, compared with commercial pharmaceutical companies.
The tightening of the U.S. embargo in the 1990s made it even more difficult and costly for the Cuban biotechnology industry to access raw materials and equipment from abroad. Although the embargo allows for exceptional circumstances, huge bureaucratic obstacles restrict trade and other forms of cooperation between the United States and Cuba in practice. These restrictions were eased under President Clinton but subsequently reversed by George W. Bush. The Obama administration relaxed some travel restrictions and reopened both embassies, but the embargo (subject to formal Congressional powers) remained in place. The 2 countries signed an accord in 2016, which promised to make health a key part of future cooperation. 57 In that same year, amendments to the embargo were proposed to allow greater medical research collaboration and access to U.S. markets for Cuban pharmaceuticals. At the time of writing, there is much pessimism about further progress on Cuban-U.S. relations under the Trump administration, following the imposition of additional restrictions on U.S. travel and business links with Cuba.
The small number of our non-Cuban interviewees who commented on this topic was overwhelmingly impressed with the progress made by Cuba in biotechnology. In particular, the production of medicines for wider social benefit rather than purely private profit was seen in a very positive light. Positive comments were also made regarding the greater potential for Western collaboration with the Cuban biotechnology sector in the future.
Consequences and Implications
Benefits for Cuba
Medical internationalism has enabled Cuba to derive economic benefits. Cuba does not routinely publish separate information on the amount of revenue it generates from its overseas health work. This is lumped together with other overseas professional services, including teachers, engineers, and military personnel. In total, professional services generated around US$9.6 billion per annum between 2011 and 2015, according to the Economist Intelligence Unit. 18 It is acknowledged that health professional services are the main component of this. For example, in 2014 it was estimated that the Cuban government generated approximately US$8 billion a year in professional health services revenue from abroad, 58 making a major contribution to meeting Cuba’s trade gap. Our interviewees commented on the financial benefits of providing health services overseas and saw it as an astute economic strategy, generating much needed hard currency.
Offering services free, or as part of international aid collaborations, has increased awareness of the strengths of Cuban health system and the expertise of its health professionals. As one of our interviewees noted, Cuba’s health care services are “becoming world renowned.” Another observed that this was due considerably to the Cuban approach to aid, which “has been good for brand awareness.” Interviewees added that Cuba’s collaborative practices in international health could provide lessons for other countries when considering their own aid policies.
Cooperation on health has been accompanied by collaboration in other sectors. Canada has engaged in trade and specific economic projects with Cuba for many years, with involvement in sectors such as leisure, energy, and minerals. It has also had solid, longstanding diplomatic and cultural ties with the island. Brazil has invested in Cuban infrastructure projects, notably the Port of Mariel development, while bilateral trade between the 2 countries increased by 89% between 2009 and 2013. 23 Although political relations between Cuba and Brazil have since cooled during the Temer government, there is still pragmatic cooperation on health and economic matters. Qatar has invested in Cuban hotels as well as collaborating with Cuba on health. 46 Norway (which has helped fund Cuban health interventions in other countries) has worked with Cuba on oil production and exploration and also cooperated with the Cuban fishing industry. General trade with China (which has collaborated with Cuba on pharmaceuticals) has increased sharply in recent years. 59 Cuba has also been able to access products on preferential trade terms with countries it has collaborated with on health – for example Guatemala, Bolivia, and Gambia. 7
As noted earlier, Cuba was able to access oil at subsidized prices from Venezuela. However, recent problems resulting from the economic crisis in Venezuela appear to have had after effects on Cuba. 60 The crisis has led to a reduction in Venezuelan oil supplies, and this appears to have affected both pharmaceutical exports (as noted earlier) and professional service exports. This perhaps indicates the risks of depending heavily on one country particularly and explains why Cuba has been seeking to strengthen economic links with other countries such as Russia, China, and the EU in recent years.
In general, the provision of Cuban health services has helped to improve political relations with other countries by creating a climate for improved diplomatic ties and bolstering support in international and regional fora. For example, it is believed that countries with students at ELAM have given greater support for Cuba in recent years partly because of the benefits they have derived from the program. 34 In particular, Cuba’s links with other Caribbean nations have improved in recent decades, in line with the provision of health services. 9 Even so, it should also be noted that Cuba has in the past assisted countries when there appeared at the time to be little chance of diplomatic gain, such as Pakistan, El Salvador, Guatemala, and Peru. 7
According to Feinsilver,8(p99) “Medical diplomacy has helped Cuba garner symbolic capital (goodwill, influence, and prestige) well beyond what would have been possible for a small, developing country, and it has contributed to making Cuba a player on the world stage.” Huish 7 echoes this, arguing that Cuba has successfully developed a form of “soft power” among nations of the Global South, increasing opportunities for diplomacy and bilateral cooperation, not just in health, but also in economic and industrial sectors. It has been particularly adept at building bridges with economically more powerful countries such as South Africa, Brazil, and increasingly China.7,46
The brilliance of Cuba’s strategy of health humanitarianism has been acknowledged even by critics. 61 Our informants also acknowledged that health internationalism had a crucial diplomatic dimension, which raised awareness of Cuba’s humanitarianism and helped improve its image abroad. As one of our interviewees (a Cuban) stated, “politically they may not like Cuba, but they like our health care.” Other interviewees acknowledged that Cuban medical aid has been successful in winning friends and strengthening alliances, especially in the Global South.
The political benefits of Cuba’s health internationalism extend to the domestic sphere. As one of our interviewees commented, overseas health missions bolster national pride and are a means to strengthen public morale. Those who have served abroad are welcomed home as heroes, as occurred for example when Cuban health care workers returned from the West African Ebola mission.
Wider Benefits
Benefits accrue to individuals who have received treatment from Cuban health services and medicines. However, this contribution is often seen as more than just a collection of services: the principles of the Cuban system are also exported. As one informant (a Cuban) said: “what we export is not just a practice but a belief in the right to a decent, healthy life.” A number of our interviewees pointed out that Cuba’s provision of services had influenced the health care systems of those countries in significant ways, not just by improving health care access but also by reorienting systems to focus more on prevention, primary care, and community-based services and addressing health inequalities.
Cuba has added to health care capacity worldwide by providing services and investing in the training of their own and other countries’ health care workers. This has been of particular benefit to countries of the Global South (and some richer countries). Cuba’s efforts also contribute to global health in other ways. Its expertise and advice to other countries enable them to strengthen their health care systems, by prioritizing primary care, integrated care, and prevention. Furthermore, infectious disease control and other public health measures undertaken by Cuban overseas missions often confer benefits beyond the borders of recipients, by halting the spread of epidemics.
Other benefits of Cuban actions are realized beyond the realm of health. Cuban medical internationalism has strengthened links between countries of the South (and in some cases with wealthier countries). South-South cooperation has been strengthened on a number of fronts and, while other factors have also played a part in this, Cuba’s efforts in the health arena have won it many friends and allies. Such activities have strengthened ties with nations receiving help and support, providing a basis for further cooperation with foreign governments.
Adverse Effects
Although most accounts of Cuban medical internationalism are overwhelmingly positive, negative aspects have also been raised. Some critics, while acknowledging that Cuba has genuinely assisted countries in need, also question the accuracy of estimates of how many people have benefited.46,61
Some host countries have expressed hostility about their use of Cuban health professionals and criticism of their training programs, noted by several of our interviewees. This has originated overwhelmingly from health professionals, in particular doctors, who have a stake in limiting competition. Such hostility has been encountered in Brazil, Venezuela, Portugal, and elsewhere.20,23,62 Also, as seen in South Africa, 32 a common complaint by the professions and fueled by the media, was that Cuban doctors lacked relevant experience and skills. As the Cuban doctors began to practice, however, the media’s views became more positive, but negative public perceptions remained. These were unfounded – even if their skills and experience did not exactly match their hosts’ needs initially, Cuban doctors proved to be quick learners. Nevertheless, critics continued to claim that funds would have been better spent hiring South African doctors, despite the large number of unfilled vacancies in poor, disadvantaged, and underserved areas where the Cubans mainly worked.
Other criticisms center on the granting of special privileges for health staff on Cuban overseas missions. As some have noted,46,63 those serving abroad receive bonuses, often in convertible currency, and are allowed to purchase consumer goods that are not ordinarily available in Cuba. This has been a strong incentive, contrasting with the relatively poor pay of health professionals back home, a point made by several of our interviewees. However, it can be argued that the Cuban overseas workers deserve some incentive or compensation. They often work in very difficult and dangerous conditions (as do other international health workers) and can face hostility from indigenous professionals, as mentioned above. Pay for Cuban health workers overseas is highly taxed, and their government gets most of the income generated. 46 In the Brazil mission, however, Cuban doctors were allowed to keep more (just over a quarter) of the original fee paid to its government. 23 This triggered an increase in the pay of health workers at home, although this remains low by international standards.
Second, it is argued that Cuban health workers suffer unacceptable restrictions on their freedoms and rights. 46 They are often separated from their families for long periods, a cause of considerable stress,32,63 a point made by some of our interviewees. Again, it can be argued that many international health workers, not just Cubans, endure this. Critics point out that Cuban overseas workers are further disadvantaged by having no control over their own labor, a violation of international labor agreements. 62 There have been cases, however, notably in Brazil and South Africa, where Cuban health workers have taken legal action to enable them to remain in countries where they have served. Another criticism is that Cuban doctors are restricted in their freedom to travel abroad and, when serving on missions, are subject to state surveillance. Doctors who have defected from Cuban overseas medical programs report close monitoring by political “handlers,” although their views may not be typical. 30
Relatively few Cubans claim asylum or defect. It has been estimated that only a fraction, less than 2% of those serving on overseas missions, took this step, 64 although the figures are difficult to verify. The U.S. government has tried to encourage such defections. In 2006, it introduced a program to fast track applications of Cuban doctors to reside and work in the United States (the Cuban Medical Professional Parole Program). This was widely criticized for seeking to undermine the health care system of an economically weaker country that had done much to improve the health of other nations. It also served to put Cuba in a positive light while making the United States appear cynical and callous. Perhaps acknowledging this, one of the last acts of the Obama administration, in January 2017, was to end this program.
A third consequence of Cuba’s overseas missions is that workers and other resources are diverted from the domestic health care system. 63 It is alleged that a lack of skilled and experienced staff as well as shortages of medical supplies have led to closure of facilities. 30 In 2010 there were cutbacks in the domestic health system to allocate staff to overseas work. The health sector was reorganized and some clinics were closed to reduce costs, associated with a 14% fall in employment in the health sector from 2009 to 2011. 61 However, it should be acknowledged that working overseas is an integral part of Cuban health system, 15 and, as noted earlier, Cuba produces one of the largest numbers of doctors per capita in the world.
Conclusions
Cuba’s international health work has previously been characterized as something of a hidden secret, or perhaps more accurately as an activity that the West chose to ignore. More recent accounts acknowledge that this is changing. 65 Although a number of factors may have contributed to the growing interest in Cuban health internationalism, including the improvement in U.S.-Cuban relations in the Obama era, one thing seems to have carried more weight than anything else: the Cuban participation in the international effort to tackle Ebola in West Africa, mentioned at the outset of this article. Our interviewees saw this as a watershed moment linked to a growing awareness of Cuba’s role and to changing perceptions about the country.
It has been acknowledged – even by critics – that Cuba’s strategy has been successful in winning friends. The Cubans have used soft power to build alliances with other countries of the South, including some of the more economically and politically powerful, such as Brazil, China, and South Africa. They have also sought better relations with the West, including the United States and the European Union.
Some of Cuba’s alliances have come under pressure in recent years. As noted above, there are tensions with Brazil, due to political and ideological changes in the latter. Cuba has suffered from the economic and political crisis engulfing its key ally, Venezuela. Meanwhile, the Trump presidency has created great uncertainty about further improvements in U.S.-Cuban relations. All these developments pose significant challenges. Although the situation is not yet anywhere near the cataclysmic economic crisis of the 1990s, the Cuban government is well aware that foreign currency earnings and much needed resources such as oil will have to come from somewhere. For the moment, closer links with the European Union, China, and Russia seem to be the way forward.
Cuban investment in overseas health care is not solely a humanitarian exercise of relieving suffering among the poor and disadvantaged. As Huish observes, “rather it is tightly associated to its own national interests in forming alternative networks of collaboration, exchange, and, most importantly, what is perceived in Cuba as resistance to dominant processes of inequity from global capitalism.”7(p7) However, as Kirk and Erisman 9 observe, a genuine humanitarian motive is present. A great many sick and vulnerable people have benefited from Cuban health internationalism.
There has been a greater emphasis in recent years, born out of economic necessity, to generate export income and foreign currency. Some see hypocrisy in Cuba selling health services to citizens of richer countries for profit. The treatment of Cuban health workers, their pay, and their conditions of work have been criticized. The impact of overseas work on the Cuban domestic health system has also been highlighted. These issues are not trivial and are a source of discontent at home as well as criticism from outsiders. Nonetheless, this activity continues, based on a rationale is that these revenues enable Cuba to provide universal health care and to secure excellent health outcomes for its people and others.
Will other countries learn from the Cuba’s health internationalism? Following the collapse of Soviet Communism and the rise of neoliberalism, Cuba was perceived as a socialist anomaly. This made its achievements in the health field difficult to accept, especially in the West, and there was a deep reluctance to consider it as an exemplar. 65 Yet, in some respects, attitudes are changing. Cuba integrates health into foreign policy very successfully. 66 Other countries have also highlighted the importance of health in foreign policy, reflected in the Oslo Declaration (2007). 67 The integration of health within foreign policy has been acknowledged by the U.N. General Assembly, 68 and a growing a number of countries have set out global health strategies, including Japan, Switzerland, and the United Kingdom.69–71 These developments reflect the growing importance of health as an issue for global governance and indicate that for many years Cuba has been ahead of the game.
Certainly, other countries could learn from Cuba’s approach to health internationalism. Development assistance for health, for example is not aligned with health needs as indicated by disease burden and national income, 72 and Cuba provides lessons in how to improve this. It produces cheap medicines that meet the needs of poorer countries. Its overseas workers tackle key global health priorities focusing on illness prevention, addressing health inequalities, and tackling the key environmental determinants of health. However, more broadly, other countries must learn important lessons about the nature of health diplomacy. As Huish and Blue succinctly state, “the lessons learned from Cuban outreach could do well to advance foreign relations in an era focused on cooperation rather than competition and solidarity rather than supremacy.”66(p9)
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the British Academy (Grant No. SG 112485).