Cuban Public Healthcare: A Model of Success for Developing Nations

Rapprochement with the USA

Cuba is very much in the news. Barack Obama, former President of the USA, announced on December 17, 2014 a new policy on the relaxation of restrictions on trade and travel, beginning January 16, 2015. President Obama’s action allowed for visits to Cuba by family members, journalists, professionals attending conferences or conducting research, students in study abroad programs, religious-oriented trips, performances, any humanitarian visit, or business trips. In May 2015, the Obama administration removed Cuba from the list of nations labeled as state sponsors of terrorism. Building upon these changes, the nations exchanged ambassadors in the summer of 2015. However, the US trade embargo remains in place; it cannot be ended without an act of the US Congress, something that seems politically impossible in the USA while the Republicans maintain majorities in the House or the Senate. Americans still cannot visit Cuba as tourists.

The administration of Donald J. Trump began to retighten trade and travel restrictions on November 9, 2017, putting in place tougher restrictions on travel to Cuba as well as making it again more difficult for US companies to do business with Cuban enterprises associated with the Cuban military, something that is common in the Cuban economy. Nevertheless, the nations’ embassies have, thus far, remained open. As these developments continue to unfold, Cuba will remain a nation of key interest in US policy (Lamrani, 2015, p. 2; Latin American Weekly Report, 2017, p. 16; Mattingly, 2015–2016, p. 42).

Historical Context: Cuba and the USA from the Nineteenth Century to the Revolution

Cuba’s history has long been one of dependency: on Spain as a colony; on the USA as all but a colony; on the Soviet Union as an aid recipient; and, more recently, on Venezuela as an aid recipient, at least until Venezuela developed its own troubles and cut deeply into its price-controlled oil shipments to Cuba. The era of dependency on Venezuela has ended, with this nation now slipping to second place in Cuba’s leading trade partners, falling behind China. Cuba, for the first time, is on its own (Feinberg, 2017; Mattingly, 2015–2016, p. 41).

Cuba is a small nation, 42,427 square miles (about the size of Virginia or smaller than the Netherlands), running some 785 miles east to west. The population of Cuba is 11 million (about the size of Ohio or smaller than Chad), with the capital city of Havana numbering two million people. Yet, for its relatively small size, Cuba has often loomed large in US history and in world affairs.

Throughout its long, tangled relationship with the USA, Cuba was frequently considered in various US annexation schemes. In 1854, the US President Franklin Pierce (1853–1857) offered to pay Spain US$130 million to buy Cuba. President James Buchanan (1857–1861) continued purchase negotiations with Spain, and President Ulysses S. Grant (1869–1877) also pursued the idea of the annexation of Cuba. Then in 1898, after nearly half a million Cubans died in winning their independence from Spain, the victorious independence fighters watched as the US forces poured in and took control of their new nation. In the twentieth century, the US military came back frequently, holding the island during the periods 1898–1902, 1906–1909, and in 1912 (when 3,000 Cubans died as US marines occupied the island, moving to protect the significant US sugar holdings), and once again from 1917 to 1922.

For much of the twentieth century, strongman Fulgencio Batista dominated the Cuban political scene, counting on considerable support from the USA. Batista first came to power in a coup in 1933, then at the rank of sergeant in the Cuban army. Batista maintained military control until 1940 when he was elected president, serving in office from 1940 to 1944. Batista returned to power in a coup in 1952, staying on until the Revolution in 1959. As scholar Clifford Staten aptly sums up, Batista’s government was “corrupt and repressive … supported by the United States [but] …. alienating its own people …” (Staten, 2005, p. 71).

Before the Revolution: Economic and Social Conditions

The USA dominated the Cuban economy before the Revolution, controlling 80 percent of Cuba’s trade. US firms ran the public utilities, the railroad, and all of the oil refineries. Two-thirds of food production came from US-owned agro-business enterprises. US developers owned half of the arable land on the island.

Cuba was a nation of great inequality before the Revolution. Just 8 percent of landholders owned three-quarters of the land. At least a quarter of the population was unemployed. One-fifth of the population received 58 percent of the income, while the bottom fifth took in just 2 percent, one of the lowest rates for the bottom 20 percent in the world, then or now (Cuba, n.d., p. 2; Staten, 2005, pp. 83–84).

Social conditions before the Revolution reflected Cuba’s economic inequality. Two-thirds of the people received three years of education or less; one-third never attended school. Half the adult population could neither read nor write. Two-thirds of the population lived in mud floor huts without potable water or electricity. Rural districts in the eastern, Afro-Cuban section of the island endured especially impoverished conditions. In the years just before the Revolution, Cuban annual per capita income reached US$374 in the cities but only US$91 in the countryside; 87 percent of urban homes had electricity, but only 9 percent or rural ones did. Rural residents were four times more likely to be illiterate as compared to city people. Only 4 percent of the rural population could afford to eat meat regularly. More than one of ten rural dwellers suffered from tuberculosis. As historian Clifford Staten has noted, “most rural homes … bohios … were … made of palm and wood, lacked running water and [indoor] bathroom[s] …, and had earthen floors” (Cuba, n.d., p. 2; Staten, 2005, pp. 81, 83–84; Whiteford & Branch, 2008, p. 33).

Revolution

On a date selected to coincide with the 100-year anniversary of independence hero José Martí’s birth, on July 26, 1953, Fidel Castro led an assault on the Moncada military outpost in Santiago, Cuba; the base was one of the most hated symbols of the Batista regime. Castro’s assault failed utterly, with 68 rebels captured, tortured, and executed; another 32 jailed, including Fidel and his younger brother Raúl; while 50 conspirators managed to escape. July 26 is today celebrated throughout Cuba, the army barracks converted into a school and museum. (Because workmen patched up the bullet holes in the Moncada soon after the 1953 attack, the subsequent Revolutionary government had to shoot new holes in order to make it appear more like a proper Revolutionary shrine.) (Staten, 2005, pp. 74–75).

Fidel wrote copiously while in prison on the Isle of Pines (located off the southern coast of the main island of Cuba), his philosophy resembling nothing so much as that of a US New Deal-style liberal. Fidel often commented on his admiration for the US President Franklin Delano Roosevelt, even carrying with him a photo of FDR. The life of Fidel Castro had long intersected with the USA, as his political philosophy evolved from nationalist to eventual conversion to socialism. In 1940, 12-year-old Fidel Castro wrote to the US President Roosevelt, congratulating him on his reelection. Said young Fidel, “if you like, give me a ten dollars bill green American” (Gilson, 2014). President Roosevelt did not send the money. Fidel Castro loved baseball, showing such promise as a pitcher that in 1949, when Castro was 21, the New York Giants offered him a US$5,000 contract. He did not sign.

Two years after Castro was jailed, Batista, in a misguided effort to win back public favor, released the Castro brothers and the other survivors from the failed Moncada raid. Castro left for Mexico, plotting his return. He came back in 1956, and after three years of guerrilla combat, on January 1, 1959, his forces poured in and occupied Havana. Batista fled to the Dominican Republic with US$300 million taken from the public treasury. Immediately after Castro’s victory, planes left Havana empty, returning from Miami with jubilant Cubans coming home from exile.

Trouble with the USA

Following the triumph of the Revolution, tension soon developed with the USA, falling into a downward spiral of action and overreaction. Cuba certainly exacerbated the situation when in 1960 it expropriated without compensation all US holdings in Cuba, seizing US$1 billion in assets. Cuba was making some dangerous enemies, including mobster Meyer Lansky, who lost US$100 million in confiscated hotels and casinos after Castro seized power. In January 1961, the Dwight D. Eisenhower administration broke diplomatic relations with Cuba and banned the US citizens from traveling to the island.

The US actions could be petty. After a New York City speech at the United Nations, Castro tried to fly home, only to find that the US government, in a move to recover some of the costs of the nationalized US assets, had seized and sold his airplane. Castro had to get a ride back to Havana with Nikita Khrushchev in a Soviet plane. But mostly, the US actions were deadly serious. In 1960, the US Deputy Assistant Secretary of State Lester Mallory urged that “every possible means … be undertaken … to weaken the economic life of Cuba … to bring about hunger … [and] desperation…” (FRUS, 1960).

The US CIA began a campaign of bombings, hitting sugar plantations, industrial sites, oil refineries, and even targets in downtown Havana. In the period up to the US-sponsored and organized effort at counterrevolution, the failed Bay of Pigs Invasion in 1961, CIA covert operations destroyed 300,000 tons of sugar, set ablaze 42 tobacco warehouses, burned down two paper factories, blew up 21 city apartments, destroyed a department store, and set off a bomb at a passenger railway station. The CIA Deputy Director Richard Bissell gave US$200,000 to the mafia to murder Castro. The mob took the money but did not carry out the hit. Fidel Castro’s on-again off-again girlfriend Marita Lorenz was given poison by the CIA to murder Castro, but Ms. Lorenz backed out at the last moment, fleeing Castro’s quarters in tears.

At the founding meeting of the Alliance for Progress in Uruguay in August 1961, Cuban representative Che Guevara held a secret meeting with the US envoy Richard Goodwin. Che offered to pay for all the properties expropriated after the Revolution, to refuse any alliance with the Soviet Union, to refrain from exporting socialist revolution to any other nation, and to hold elections, all in exchange for a US promise to not again invade Cuba, as it had in the Bay of Pigs. Nothing came of this conversation, and Goodwin was called before the US Congress to explain why he had even talked to Che. Goodwin informed the lawmakers that the best course of action would be to bomb Cuban industries.

After the Bay of Pigs, the President’s brother, US Attorney General Robert Kennedy, spearheaded the US$50 million “Operation Mongoose,” a CIA program to kill Castro and Che and invade Cuba. There were various US plots to assassinate Castro, including one in July 1961 which also called for murdering Soviet cosmonaut Yuri Gagarin. The CIA had 12,000 Cuban exiles in Miami on its payroll, bankrolling their violent anti-Castro activities over the years. In all, the USA launched 7,000 attacks against Cuba, leading to 3,478 deaths (Lamrani, 2015, p. 6; Pérez, 1988, pp. 325, 336, 347–348).

As historian Louis Pérez, Jr. has reported, the USA also carried out economic sabotage. “Corrosive chemicals were added to lubricating fluids … [and] ball bearings were manufactured deliberately off-center” (Pérez, 1988, p. 348). The CIA engaged in economic–biological warfare, spreading disease to Cuba’s hog population, resulting in the slaughter of half a million animals with swine flu. At length, however, in the 1970s US President Lyndon Johnson (1964–1969) ended most covert US operations against Cuba, preoccupied as Johnson was by the US involvement in the war in Vietnam (Pérez, 1988, pp. 348–349).

The History of the Embargo

By 1961, the USA had established an economic blockade against Cuba, seeking to stop all nations from trading with the nation. US officials use the term “embargo,” but Cubans prefer the term bloqueo or blockade. They have a point. An embargo would be a situation where a nation decides not to trade with another. A blockade, such as the US still has in place against Cuba, is where a nation seeks to prevent all other nations from trading with another nation.

By whatever term, the US policy has brought serious health repercussions for Cuba, halting the importation of food, medicine, and medical equipment. Under the terms of the embargo, as modified in 1963, medicine and medical equipment could not be imported. While now many medicines can, at least technically, be imported from the USA, the rules remain so bafflingly complex that few US prescriptions drugs actually reach Cuba. One key obstacle is that all sales must be in cash, not on credit, as is otherwise commonly the case in most other international transactions. As partial solution, by the 1980s Cuba had developed the capacity to produce most of its own medicines (Drain & Barry, 2010, p. 572; Mattingly, 2015–2016, p. 41).

The US Congress tightened the embargo in 1992 under the Torricelli bill, banning vessels from coming to the USA if they had called in Cuba within the past half year. In 1996, the US Congress, with the Helms-Burton Act, added fines and even jail time for those individuals or companies which traded with Cuba. Philips Electronics, for example, received hefty fines from the US Office of Foreign Assets Control for selling medical equipment to Cuba. The European Union issued a formal complaint against this action. To date, the US economic blockade against Cuba has continued under 11 successive American presidential administrations. The Organization of American States has ruled the US embargo on food and medicine as a violation of international law. The shortage of medicines due to the bloqueo has resulted at points in increases in the incidence of tuberculosis in Cuba and occasional spikes in diarrheal diseases due to the shortage of chlorination chemicals for potable water supplies. According to Amnesty International, “the export of medicines and medical equipment [from the United States to Cuba] continues to be severely limited and has a detrimental impact on … health” (Bustamante, 2017, p. 215; Drain & Barry, 2010, pp. 572–573; Gorry & Keck, 2015, p. 412; Latin American Economy & Business, 2017, pp. 8–10; LeoGrande, 2015b, p. 473; Scheye, 2009, p. 384; Whiteford & Branch, 2008, p. 30).

Attitudes about the US trade embargo and overall US hostility toward Cuba have softened markedly in recent decades, especially with the end of the Cold War. Already by 1996, polls showed that two-thirds of Americans opposed the embargo against Cuba. Even Cuban-Americans in south Florida no longer support the embargo. A November 2008 poll by Brookings and Florida International University of Cuban-Americans living in south Florida found for the first time in that year that even a majority of these individuals supported lifting the embargo (Pérez-Stable, 2010, p. 56).

In 2009, the Organization of American States repealed Cuba’s suspension from the body, a ban in place since 1962. Cuba is free to reapply for OAS membership, but has shown no interest in doing so, labeling the organization “totally anachronistic,” a “pestilent corpse” (Trebel, 2009). In 2012, the nations of Latin America informed the US government that there would not be another summit of hemispheric nations unless Cuba was invited to attend. President Obama relented, meeting with Raúl Castro at the Summit of the Americas held in Panamá in 2015 (Weisbrot, 2015). The United Nations General Assembly has voted against the US embargo every year since 1992, with only Israel consistently joining the USA in voting in support. In 2016, under President Obama, the USA abstained for the first time in the UN vote condemning the embargo. Nevertheless, President Donald J. Trump has returned to prior practice, with the US voting in the UN in support of the embargo. The embargo remains a central impediment to the health of the Cuban economy; lifting the US embargo would likely boost Cuba’s GDP by 5 or 6 percent annually.

Battered: From the “Special Period” to Hurricanes

When the Soviet Union began to implode in 1989, its annual US$5 billion aid allocation to Cuba began to plummet dramatically before halting altogether. This cut in support brought devastation to Cuba, its GDP dropping by an astonishing one-third from 1989 to 1993. Cuba’s total foreign trade fell by 80 percent, a time the Cuban leadership came to euphemistically term the “special period.” In 1993, Cuba’s economy contracted by 14.90 percent. Gasoline supplies, previously provided at below cost from the Soviet Union, dried up. In 1987, Cuba had imported 7.8 million tons of Soviet oil; in 1995, it took in just three million tons. As gasoline grew scarce, half of Cuban families turned to bicycles to get around. On farms, oxen replaced tractors. Recovery was slow. By 2000, the Cuban economy was still 18 percent below its 1989 level (De Vos et al., 2012, p. 471; Huish, 2013, p. 27; Mesa-Lago, 2009, p. 368; Sixto, 2002, pp. 325, 328, 333; Whiteford & Branch, 2008, pp. 31, 86).

Cubans suffered greatly during the special period. Food imports fell by at least half between 1989 and 1993, leading to a one-third drop in average caloric intake per person. The average weight of adult males in Cuba dropped by over 20 pounds. To try to spare infants from deprivation, Cuban doctors returned to strongly encouraging mothers to breastfeed their infants, the practice rising from around two-thirds of mothers in 1990 to nearly all mothers by 1994.

As cuts came to Cuba’s social support programs, the government gathered communities together to share information and to seek consultation. Starting in 1994, Castro relaxed the prohibition on farmers’ markets, making vegetables much more widely available. Cuba began steadily shifting from vast, Soviet-style collective farms to community and individual plots. The government set in place food rationing programs, with at least half of island agricultural production targeted for food rations. With the vast drop in food imports, urban people planted vegetable gardens in their backyards or in nearby vacant lots. By 1998, Havana residents had sown over 26,000 community gardens, usually collective efforts, with everyone in the neighborhood expected to participate. Intriguingly, as urban Cubans shifted their diets from imported foods high in fat, sugar, and salt to home-grown fresh vegetables, rates of heart diseases and hypertension fell markedly. Still, this good news in Cuban public health might well have been seen as rather cold comfort for those people who, after a long day in the office or factory and a long walk or bicycle ride home, were pressured by their neighbors into trooping out to the community garden to scratch around in the dirt for a few hours to dig up radishes, turnips, and cabbages for dinner. But by the end of the 1990s, Cuba had largely recovered in food production, with levels at nearly twice where they had been at the start of the decade. Nevertheless, Cuba continues even now to import most of its food needs. The response by Castro to the food crisis during the special period demonstrated at least one benefit of an authoritarian system: the government could act immediately and in a cohesive manner without having to line up political support or make compromises with quarreling political interests (Bustamante, 2017, p. 215; De Vos et al., 2012, p. 475; Huish, 2013, p. 40; Kirk, 2009, p. 277; Sixto, 2002, p. 333; Whiteford & Branch, 2008, p. 86; Wright, 2012, pp. 130, 135, 138–139).

“The crisis,” according to scholar Felipe Sixto, “had a negative impact on the importation of medical equipment, spare parts and medicines” (Sixto, 2002, p. 328). The Soviet Union had previously provided 94 percent of Cuba’s medical equipment. With the loss of Soviet oil imports, down by nearly two-thirds, ambulances sat in parking lots and electricity to hospital operating rooms and clinics was not there when doctors and nurses flipped the switches. It certainly did not help matters that the US ratcheted up its economic embargo in these years. As a consequence, the special period brought a serious deterioration in potable water and sewer services. The percentage of chlorinated potable water dropped from 98 percent in 1988 to just 26 percent in 1994. Deaths from diarrheal diseases more than doubled. Cuba likewise saw many more low-birthweight babies in these years (De Vos et al., 2012, pp. 469, 473; Gorry & Keck, 2015, pp. 409–410; Sixto, 2002, pp. 328, 330, 332, 333, 338).

In the face of the crisis, Fidel Castro’s government sought above all to protect public health; he did not close any hospitals or medical schools during the special period, even if there were nearly no supplies for upkeep or repairs. Because Cuba had no relationship with the International Monetary Fund or the World Bank nor any interest in their counsel, Castro did not have to impose the sort of austerity programs that these institutions routinely demanded elsewhere. Instead, expenditures for public healthcare rose during the special period, doubling as a proportion of the budget. Castro saved money by mandating deep cuts in military spending, with the number of soldiers reduced from around 300,000 to 49,000. Castro slashed the military budget by half, calling home nearly all of the troops stationed abroad, especially in Africa.

As a result of these actions, Cuba’s public health situation actually improved during the special period. During these years, the doctor-to-patient ratio improved threefold, and the number of consultarios (local doctors’ offices) rose from 6,000 in 1989 to nearly 16,000 by 1998. The infant mortality rate fell during the special period, dropping from 17 per 1,000 live births in 1985 to 7.2 in 2000, and overall life expectancy lengthened (De Vos et al., 2012, pp. 469–479; Huish, 2013, pp. 28, 41; LeoGrande, 2015b, p. 476; Spiegel & Yassi, 2004, pp. 86, 88, 102; Thomas, 2016, p. 195).

If the economic bloqueo and the special period were not enough, from 1998 to 2008, Cuba suffered through 16 hurricanes, smashing the island and bringing US$20 billion in damage. In 2008 alone, three hurricanes caused the Cuban GDP to contract by one-fifth and destroyed or damaged 600,000 dwellings. There was another punishing hurricane in 2012, Sandy, and then Irma roared through in September 2017, leaving behind yet more destruction (Feinsilver, 2010, p. 86; Gorry & Keck, 2015, p. 413; Kirk, 2012, p. 77; Mesa-Lago, 2009, pp. 369, 379).

Changes in the Cuban Economy

In response to the many economic challenges, Fidel Castro began during the special period to open the economy to some elements of the free market. But as Cuba began to recover, in 1996 Fidel slowed the opening process before reversing this impulse entirely in 2003. A new donor, Venezuela under leftist ally Hugo Chávez, began to offer generous aid to Cuba, especially low-cost oil, which Cuba could use or resell on the international market (Henken & Ritter, 2015, p. 73; Mesa-Lago, 2009, p. 369).

In the midst of all this came a change of political leaders. Fidel fell ill in 2006 with diverticulitis, and his brother Raúl Castro took over as acting president. In 2008, Raúl Castro became president, elected by the Cuban national assembly. He retired from this post in 2018 after the second of two five-year terms, at age 87.

Responding to Cuba’s long-term problem of low productivity, Raúl started a series of basic economic transformations, steps which grew out of his experiences in managing the Cuban military’s many economic enterprises. The changes were long overdue. As Fidel admitted in 2010, “the Cuban model doesn’t even work for us anymore” (Sweig & Bustamante, 2013, p. 101). Focused on increasing Cuba’s economic efficiency, in 2009, Raúl conducted a wide-ranging and inclusionary consulta, or dialogue, with the Cuban people. Under Raúl, decision-making became much more collective, more institutionalized, and far less impulsive, individualistic, and idiosyncratic than it had been under his brother Fidel. Cuba is moving on from the revolutionary-era leadership, los históricos, to a new generation.

Ordinary Cubans can now take advantage of vastly more opportunities to work for themselves or start their own small businesses. Before Raúl Castro’s reforms, only about 15 percent of the labor force worked outside of the state-run sector, but today about 40 percent do. Like China and Vietnam today, Cuba now “share[s] the belief that the market should not be identified exclusively with capitalism,” as analysts Burbach, Fox, and Fuentes have noted (Burbach, Fox, & Fuentes, 2013, p. 145), developing, as Cuba scholar William LeoGrande has termed it, a “market socialist economy” (LeoGrande, 2015a, p. 377). In this manner, the market is increasingly used to help distribute goods more efficiently. Yet, Raúl was mindful of the fact that this economic opening can lead to increased social inequity. Accordingly, the process of economic change is being closely monitored. “I was not elected president to restore capitalism in Cuba nor to surrender the Revolution,” Raúl cautioned (LeoGrande, 2015a, p. 392).

Other changes have come. Beginning in 2008, under Raúl, Cubans could lawfully purchase cell phones, computers, stay in the heretofore restricted tourist hotels, and rent cars, provided of course that they could afford any of this. Cuba still ranks last in Latin America Internet and cell phone coverage, worse than even Haiti. As reporter Karl Vick commented, “there’s almost no Internet outside major hotels, and [Cuba still has but] a creaking cell network [that] won’t support smartphones” (Vick, 2015, p. 34). It is not uncommon to see Cubans leaning up against the walls just outside of tourist hotels, tapping into resorts’ Wi-Fi signal. In 2013, Raúl also ended the tarjeta blanca (travel permission slip) requirement, making it much easier for Cubans to leave the island if they want. Nevertheless, the destination country still has to be willing to accept the travelers, and the US quota (20,000 per year) is still in place (Burbach et al., 2013, pp. 144–145; Henken & Ritter, 2015, p. 75; Kapcia, 2012, p. 72; LeoGrande, 2015a, pp. 377, 388, 391, 396; Mesa-Lago, 2009, pp. 369, 379).

Political oppression has remained a serious concern in Cuba, although this situation was hardly unique to the Castros, least of all to the prior Batista regime. Still, by 1965, Fidel Castro had jailed some 20,000 political prisoners, opponents of the Revolution. From 1959 to 2000, at least one million people left Cuba (10–15% of the population), although many of these people were economic refugees, not individuals fleeing political persecution. The usual monthly average of political detentions in Cuba, as reported by the US Department of State, is around 178, compared to 741 a month in 2014. Yet even today, it would be fair to label Cuba a largely un-free society, with only state-run mass media permitted (Kapcia, 2012, p. 70; Staten, 2005, p. 4; Vick, 2015, p. 39).

Under the Revolution: Economy Not So Good, but Great Healthcare

Since 1959, as University of Pittsburgh researcher Carmelo Mesa-Lago has found, while most Cuban economic indicators have declined, most social and health indicators have improved markedly, especially in rural zones which had the most catching up to do. At the time of the Revolution, Cuba was already well ahead of most Latin American nations in general economic conditions, boasting the third highest GDP per capita in the region, after Venezuela and Uruguay. By 2005, however, Cuba had slumped to 12th in Latin American per capita GDP. To be sure, there have been some good economic periods, for example from 1971 to 1980, when, boosted by Soviet aid, the Cuban GDP rose at a very healthy average of 5.7 percent increase per year. But Cuba’s economic growth has been uneven in recent years. With Cuba’s previously key trading partner, Venezuela, presently in economic freefall, the Cuban economy has flattened. While the GDP had grown at around 3 percent a year from 2011 and 2015, the key period of generous Venezuelan support buoyed by soaring oil prices, in 2016, the Cuban economy actually contracted by 1 percent. The forecast for the next several years is not encouraging (Bustamante, 2017, pp. 8–10; Mesa-Lago, 2009, pp. 368, 371–372; Pérez, 1988, p. 354).

In overall public health measurements, Cuba actually showed comparatively good numbers before the Revolution, at least in its aggregate metrics. Cuba was the first nation in Latin America and the Caribbean to create a Ministry of Health, taking this important step in 1902. As researcher Mesa-Lago has correctly pointed out, on the eve of the Revolution, Cuba ranked among the leading Latin American countries in life expectancy and infant mortality. Cuban life expectancy had reached 64 years in 1959, better than most developing nations, but lagging behind the levels found in industrialized nations at the time. The Cuban infant mortality rates before the Revolution stood at 32 per 1,000 live births, the lowest rate in Latin America (compared to 81 in Mexico and 127 in Chile); the Cuban level was about equal to the best rates then found in Western Europe and Japan. Yet despite these good health indicators, Cuban medical care remained concentrated in urban areas, chiefly serving the White middle class and the elite. Healthcare was highly segregated, with Afro-Cuban patients routinely denied service in Whites-only facilities. Most facilities were located in Havana, home to at least two-thirds of doctors and nurses. Two-thirds of the hospital beds were in the city, even though the capital city was home to less than a fifth of the overall population. The nation operated only one hospital in the rural countryside before the Revolution, providing a total of only 10 beds (Cotlear et al., 2015, p. 1252; Cuba, n.d.; Fitz, 2016, pp. 48, 53; Giovanella et al., 2012, p. 22; Huish, 2013, pp. 27, 35, 36; Mesa-Lago, 2009, p. 368; Pérez, 1988, p. 343; Sixto, 2002, p. 326; Staten, 2005, p. 81; Stusser, 2013, pp. 369–380; Werlau, 2010, p. 143). As scholar Louis Pérez has summed up, despite some good overall comparative numbers, before the Revolution “the medical needs of vast sectors of the population were unattended” (Pérez, 1988, p. 362).

Even when Fidel Castro was in jail in 1953 on the Isle of Pines, he wrote in the letters smuggled out of his concerns over Cuban healthcare. Yet in the years immediately following the Revolution, Fidel focused more on issues other than health, giving more attention to land reform, income redistribution, literacy, and assuring a supply of basic necessities for all. Castro did not come to focus on health matters until he began to realize that Cuba’s doctors, mostly drawn from the middle class, were fleeing the island, rejecting the goals of the Revolution. Castro turned his venom on these medical caregivers, repeatedly denouncing the departing doctors as selfish “worm-like” people (Cuba, n.d., p. 4; Staten, 2005, p. 74).

Just prior to the Revolution, Cuban healthcare had taken a step backward. In 1957, Batista, battling his many opponents, turned his wrath on student activists and shut down Havana’s medical school. This was a venerable institution, one of the first schools of medicine in the Americas (in operation since 1728). Cuba’s physicians came from the better-off families, and they came to deeply oppose Castro’s Revolution. By the early 1960s, only 17 of the 260 medical faculty remained at the medical school. Castro had to bring in teaching doctors from Argentina, Mexico, Ecuador, and the Soviet Bloc (Fitz, 2016, p. 47).

There was much that the Batista-era Cuban medical establishment objected to after the Revolution. Castro not only banned the lucrative private practice of medicine but also took over the mutual aid organization facilities that had previously served organized middle-class urban groups. But there was no turning back. Beginning in 1965, Cuban doctors promised in their graduation oath not to engage in private medical practice for profit. Changing everything, Castro welcomed Cuba’s poor underclass into medical school, with the government paying the bills for all of the costs associated with their training. Once a preserve of the upper class alone, these changes were something that most of Cuba’s well-to-do doctors could not stomach. As they fled for Miami, Cuba’s ratio of physicians to patients dropped from 9.2 doctors per 10,000 people in 1958 to 5.4 by 1962.

In time Cuba slowly began to build a new corps of Revolutionary-era doctors, and the physician-to-patient ratio improved: 36.1 doctors per 10,000 people in 1990; 59 in 2000; to 64 per 10,000 in population in 2007. By the 1990s, Cuba’s doctor-to-patient ratio resembled that of most nations in the world. By 2007 Cuba had a better doctor-to-patient ratio than that of USA or Western Europe. Today, Cuba’s ratio is about double that found in developed nations, with a doctor for every 150 people. In Latin America as a whole, the ratio is 0.2 doctors per 10,000 people. What is more, Cuban doctors are not just available to city dwellers, as is the case in most of Latin America, but are readily available to Cubans who live in the countryside. As Pérez has written, after the Revolution, the “urban-rural imbalance was gradually redressed … The construction of new health facilities favored the countryside over the cities” (Pérez, 1988, p. 363). Moreover, today 57 percent of doctors in Cuba are female, something that was certainly a distinct rarity in Cuba before the Revolution. Cuba has also realized progress in nursing and dental care. In 1958, Cuba had 1.9 nurses per 10,000 people in population; by 2000, it was 74.3. In 1965, Cuba had 1.5 dentists per 10,000 in population; by 2000, it was 8.9 (Cuba, n.d., p. 9; Feinsilver, 2010, p. 87; Hill, 2015; Huish, 2013, pp. 37, 40; Kirk, 2012, p. 78; Mesa-Lago, 2009, p. 376; Pérez, 1988, p. 363; Sixto, 2002, pp. 326, 330–332; The Economist Intelligence Unit, 2013; Werlau, 2010, p. 154; Whiteford & Branch, 2008, p. 19).

Cuban Healthcare: A Focus on Prevention and Community Involvement

The notion of focusing above all on preventative healthcare was most forcefully advanced on the world stage at the 1978 international meeting of health experts organized by the World Health Organization (WHO) in Alma-Ata, Kazakhstan (then in the Soviet Union). This vision had been articulated by the WHO in its founding document in 1948, but Alma-Ata pushed this concept forward much more aggressively, providing a deeper understanding of the benefits of preventive and community health measures over orthodox curative medicine, and, even more controversially, making it plain that it was the responsibility of the state, not the market, to provide health services to the public. The 1978 Alma-Ata model called for the construction of rural clinics as opposed to expensive urban hospitals, and the training of medical auxiliaries, rather than physicians focused on costly specialties. As Marcos Cueto and Steven Palmer note, writing in their book Medicine and Public Health in Latin America, this approach grew directly out of the recognition that “the principal diseases of poor countries … [are] caused by malnutrition, cold, poor water, and poor living conditions” (Cueto & Palmer, 2015, p. 204).

The idea of the state taking the lead in addressing common health concerns, agreed upon at Alma-Ata, was just the latest version of the philosophy of “social medicine” initially put forward by German social thinker Rudolph Virchow (1821–1902). These understandings were used in Chile to inform health policy during Salvador Allende’s tenure as Chile’s Minister of Health, 1938–1942.

Following this time, however, the notions of social medicine came to be routinely brushed aside, dismissed during the Cold War years by medical establishments and free market enthusiasts as not much more than a tepid version of failed, Soviet-style socialist medicine. However, in 2001, the WHO issued a report declaring healthcare a basic human right, the most basic building block for any nation to advance in economic development. Following up, in 2004, the WHO created its Commission on Social Determinants of Health to advance its vision of healthcare for all, with the leadership role to be supplied by the state (Belén Herrero & Tussie, 2015, p. 263; Birn & Nervi, 2015, pp. 1174–1175; Cueto & Palmer, 2015, pp. 208, 219; De Vos & Van der Stuyft, 2015, p. 364; Hartmann, 2016, pp. 2145–2151; Muñoz, 2011, p. 171; Whiteford & Branch, 2008, pp. 20, 37, 41, 51).

It is helpful to consider healthcare as a four-tiered system, moving from measures that do the least to lower overall mortality to those steps that do the most to save lives. Curative medicine ranks the lowest in this regard. While doctors today can do wonders, seeking to cure people after they are already sick may come too late to save many of them. Preventive measures, like vaccinations or mosquito abatement, are nearly always less expensive and can often obviate the need for costly curative steps. The provisioning of adequate supplies of potable water and sanitation saves even more lives and is especially critical in reducing infant mortality, especially from diarrhea. Even just a 1 percent increase in community potable water coverage can lower the infant mortality rate by one, that is, one child’s life is saved per 1,000 live births per year. Progress in lowering infant mortality is most valuable of all, for when a child’s life is saved, they can ordinarily go on to expect to live a long life. Progress in lowering infant mortality does the most to improve a nation’s overall population life expectancy.

But the most effective way to improve public health is to reduce poverty and inequality. People who can afford to buy adequate food supplies will benefit from the protection of their more robust immune system; when exposed to disease, a well-nourished individual’s own natural immune system has a better chance to mark and clear any invading affliction. Poverty and inequality are the leading killers in our world today. As Kawachi and Wamala note in their 2007 Oxford publication on globalization and health, “a country or region with greater inequality … [especially those in the developing world,] will have worse average health status than a country or region with a more egalitarian distribution of incomes” (Kawachi & Wamala, 2007b, pp. 125–126). Inequality kills. As Dr. Martin Luther King once remarked, “of the forms of injustice, inequality in healthcare is the most shocking and inhumane” (Huish, 2013, p. 7).

As researchers Brain Biggs et al stated in their 2010 essay in Social Science & Medicine, while economic growth might improve a nation’s health situation, this comes only if economic expansion is joined with the lessening of inequality and significant poverty reduction (Biggs et al., 2010, pp. 266–273). In sum, healthcare can be affordable for developing nations if they focus on the less expensive preventative measures that save the most lives. Most importantly, what proponents of social medicine most agree upon is that the state must play a central role in providing healthcare to its citizens as a basic human right (Hartmann, 2016, p. 2145; Huish, 2013, p. 35).

In Cuba following the Revolution, food rationing served to make basic foodstuffs more readily available to nearly everyone, people who had suffered greatly from lack of adequate sustenance before the Revolution. The Revolution, as Cuban historian Louis Pérez has put it, “eliminat[ed] … malnutrition” (Pérez, 1988, p. 361). By the 1980s, the daily caloric intake of Cubans was better than that found in most nations of Latin America. However, these gains were compromised during the special period, a time when real wages fell by 37 percent in Cuba. Even today, roughly half of Cuban households still have trouble meeting basic food needs. As Cuba analyst Julia Sweig puts it, “salaries in the state sector remain woefully insufficient for daily expenses” (Pérez, 1988, p. 362; Sweig, 2012, p. 259; Whiteford & Branch, 2008, p. 86; Zabala Argüelles, 2015, pp. 194,195, 197).

Food rations in Cuba today only go so far each month; after that families have to make their purchases from the much more costly popular markets or the black market, where prices can be literally hundreds of times higher. As a result, nearly everyone relies on additional sources of income to get dollars to buy goods at the US dollar-denominated stores. Those with family members abroad are advantaged, as Cuba takes in some US$1–US$2 billion a year in foreign remittances to families. Still, poverty in Cuba is of a different order than that found elsewhere in Latin America and the developing world. Basic food supplies are subsidized, as too are electricity and water, and health and education come free or all but free (Espina Prieto, 2010, p. 26; LeoGrande, 2015a, p. 380; Mesa-Lago, 2009, p. 375; Ritter, 2015, pp. 207, 209).

Development of Cuban Healthcare

Cuba labored through trial and error—many errors—to develop its own unique system suited to the special conditions and challenges its population faces. Cuba did not simply copy and apply a model developed elsewhere, but it is the one nation in the world to most embrace the vision of Alma-Ata.

In Cuba, healthcare, along with education, housing, transportation, and basic necessities, is either free or available at a nominal charge. The Cuban medical system focuses on consultation with patients and local communities, disease prevention, directing scarce resources toward the groups most in need, especially expectant mothers, infants, children, and the infirm elderly. Cuba practices social medicine, dealing more with the conditions that lead to poor health—nutrition, potable water, sanitation, vaccination, mosquito control—giving less focus to expensive curative treatments. Its commitment to this approach was underscored in the 1976 constitution in article 50, which assured universal healthcare. Deepening this commitment, Cuba often works cooperatively with the WHO and the Pan American Health Organization (PAHO), responding actively to special initiatives from these and other international health agencies, providing much-needed financing, as well as external ratification, for Cuba’s healthcare model (Thomas, 2016, pp. 203, 209). In Cuba, health is regarded as a basic human right, not as a purchasable commodity.

Beginning in 1984, Cuba began implementation of its “one doctor plus one nurse team” approach (called Basic Health Teams), with each team unit caring for 80–150 families. The healthcare teams must live in the communities that they serve so that they can better understand the local health issues. Usually, the doctor’s offices are on the first floor of their clinic, where the staff treats patients most mornings. Upstairs are the healthcare team’s living quarters, the dwellings provided free of charge. In recent years, Cuba added public health experts to the doctor/nurse teams, the public healthcare specialist’s core tasks focusing on mosquito abatement, monitoring potable water supplies, and inspecting sewer line hookups. Cuba has made a massive commitment of labor power to health, with more than one of ten workers in the nation employed in some way in the health service sector.

The healthcare teams develop a strong understanding of the families they treat, in no small measure because Cuban people do not move much. Most people just stay put, the government regulations restricting migration and rules complicating the sale of one’s home, at least until very recently, effectively keeping people from changing their domiciles. Every 15–20 doctor/nurse/public health official teams are supported, in turn, by local Group Health Teams, which meet regularly to scout for common issues facing the populations they serve, keeping very careful records of their findings and reporting up to the Ministry of Public Health.

Rather than waiting for people to get sick and come into doctors’ offices—the common practice elsewhere in the world—the Cuban doctor/nurse/public healthcare worker groups spend their afternoons walking about their assigned districts, medical bags in hand, dropping in unannounced on the homes of those living in their catchment zones. If the team is in a rural or spread-out urban zone, the health teams may be provided a car and a ration ticket for fuel to facilitate their visits.

In this way, the healthcare professional teams are much more likely to notice medical conditions of the people they serve before most afflictions can grow to become too serious. The teams use their house calls as opportunities to remind residents to take their medications (supplied free or at very low price-controlled costs), to exercise more, and usually quiz their patients closely about their daily diets. During the special period, Castro charged teams with a nationwide effort to assure food security, directing the teams to check on basic food supplies in each household. Today, most healthcare teams see every individual in their community at least twice a month, whether household members are sick or in good health.

Some people in the communities welcome these visits, especially shut-ins who truly appreciate the company and the concern shown over their general welfare. Without a doubt, many other people resent these uninvited intrusions by healthcare professionals, seeing the drop-in visits as invasions of their privacy. Some people would probably much prefer not to spend their afternoons suffering through a grilling by their doctor followed by didactic hectoring from well-meaning healthcare providers.

A key team focus is on the gathering of data, information that the healthcare professionals are required by the government to write up and present at one or more of the many local meetings with community groups (consejos populares, open sessions held usually once a month) as well as at mandatory medical research conferences at the local, regional, and national levels, the proceedings published in the attendant journals. The data mapping efforts are often assisted by medical students in training. This undertaking has often proved invaluable for Cuban public health, for example proving particularly helpful in pinpointing where to spray insecticide to kill mosquitoes and control the spread of the Zika virus. Given Cuba’s ongoing research and data gathering programs, as well as the authoritarian nature of its government, if a local problem is identified and documented, resources can be swiftly made available from the central authorities (Garrett, 2010, pp. 61–73; Huish, 2013, pp. 39–40, 44, 97; Kath, 2006, pp. 355–356; Thomas, 2016, p. 198; Weissenstein, 2016; Whiteford & Branch, 2008, pp. 21, 23–24, 28, 41, 43, 47–48; Wright, 2012, p. 134).

The Cuban healthcare model is much different than the ordinary health practices that most people in the world are familiar with, and as a result can often trigger criticism from those who have only seen medicine as practiced under the curative model deployed in the developed world. If, for example, a Cuban patient tests positive for hypertension, the doctor/nurse team would not usually prescribe medication to lower their blood pressure. Cuba cannot usually afford to provide the medicine, especially given the US economic blockade. Instead, the doctor and nurse team would visit the patient unannounced all the time, demanding to know what the patient has been eating, insisting that the patient eat a proper diet and get regular exercise. Without a doubt, many individuals do not much appreciate these doctor visits, the probing personal questions and blunt directives, but this overall approach to healthcare is the best one that Cuba can afford. Data from the WHO and PAHO confirm that this system is working reasonably well in lowering the overall incidence of those dealing with conditions like hypertension. However, if a Cuban patient ignores the counsel of their medical caregivers and as a result ends up requiring much more expensive curative treatments, they usually cannot expect to receive anything more than palliative care, especially if they are elderly and suffering from other complications (Spiegel & Yassi, 2004, p. 98). For families with aged loved ones suffering from these maladies, this sort of medical triage can seem astonishingly heartless.

Some observers note that many people in Cuba feel the need to offer gifts or favors to doctors in exchange for treatment or medicine, largess which is gratefully accepted (Scheye, 2009, p. 384). Not every aspect of medical care in Cuba is free. As researcher Elizabeth Katz has noted, “patients are often required to bring their own soap and sheets when admitted for surgery” (Kath, 2006, p. 354). Health writer Laurie Garrets adds that Cuban patients also have to pay for and bring “their own syringes … and towels” (Garrett, 2010, pp. 61–73). While in the hospital, the medications are free to patients, even if some needed drugs may not always be available. But after discharge, as researchers Spiegel and Yassi note, most patients must “pay for drugs, hearing, dental, and orthopedic prostheses, wheelchairs, crutches and similar items” (2004, pp. 97–98). Still, the prices are nearly always very low, heavily subsidized by the state, and for low-income patients, all these items are indeed covered free of charge. Once at home, the doctor/nurse team come around frequently to handle any follow-up needs, again, free of charge. Overall, in Cuba, about 10 percent of all health costs are covered by out-of-pocket outlays, the lowest level among all Latin American countries (Atun et al., 2015, p. 1237). Doctors write prescriptions for patients to fill at very low prices at the government-operated pharmacies, the only ones operating lawfully in Cuba (Newman, 2012).

To cut down on expensive and often unnecessary hospital visits, Cuba expanded the number of community polyclinics, typically staffed with about 12 physicians selected from specialties that help assure that they can deal with the leading health concerns of their designated zone. Each facility handles a catchment of 15,000–30,000 people, the hub for usually 20–40 doctors’ offices. Cuba started building polyclinics in urban zones in 1962 but changed the emphasis to constructing rural facilities in 1974. By 2009, Cuba had opened the doors on nearly 500 polyclinics, spread throughout the island (Kath, 2006, p. 356; Scheye, 2009, p. 383; Sweig, 2012, p. 261; Thomas, 2016, p. 191; Whiteford & Branch, 2008, p. 20).

As for hospitals, before the Revolution, these facilities could almost only be found in cities. By 1989, Cuba had 64 rural facilities. Overall, urban and rural, in 1958, Cuba had 230 hospitals, a number increasing to 270 in 2000, before dropping 152 today, given the rising use of polyclinics instead. Cuba operated 140 polyclinics in 1958, 440 in 2000, but today has 498 (Cuba, 2015, p. 14; Drain & Barry, 2010, p. 573; Sixto, 2002, pp. 325, 331; Thomas, 2016, p. 191).

The number of beds in medical facilities has grown remarkably under the Revolution. In 1958, these facilities could offer only 4.2 hospital beds per 1,000 in population but by 1995, the number had increased to 6.1 beds per 1,000, before falling to 5.2 in 2000 as the doctor/nurse team model began to show meaningful results, treating patients preventively and keeping them out of the hospitals. By 2009–2011, Cuba could offer 5.1 beds per 1,000 people, a better rate than the 2.1 level in Latin America and the Caribbean, and even better than the 3.0 rate found in the USA. It is doubtless the case that Cuba is overbuilt in hospital bed capacity, especially in urban zones. Many beds are left unused: in the year 2000, the bed occupancy rate was but 69.4 percent. With the healthcare system focused on prevention and the doctor/nurse/public healthcare worker teams keeping in steady contact with their communities, the need for hospital beds has been reduced (PAHO, 2012; Sixto, 2002, p. 330).

Public Health

Cuba has made great strides in the provisioning of potable water and in providing sanitation services, extending water and sewer lines beyond urban areas into hard-to-reach rural areas. In 1970, 56 percent of the Cuban population had access to potable water. By 1999, 92 percent did. According to the PAHO, by 2010, 94 percent of Cubans had access to potable water, compared to 79 percent in the developing world as a whole. PAHO reported that in 2010, 91 percent of Cubans had sewer hookups for their homes, up from only 44 percent of homes in 1970 (Cuba, n.d., p. 8; PAHO, 2012; Sixto, 2002, p. 329).

Vaccination coverage has shown strong positive growth. After limited early efforts beginning in 1962, Cuba launched a mass vaccination program in the early 1970s, training lay people to inject the vaccines. There was no apparent ill effect to this approach; one does not have to be a doctor to safely provide an injection, and some vaccines can be given orally. During the early years of the Revolution, greatest emphasis was placed on polio and malaria eradication campaigns, achieving considerable success.

Cuba began a polio vaccine program in December 1961, using the Sabin live oral vaccine, provided by the Soviet Union. At the time, the USA still used the marginally less effective Salk injectable killed virus vaccine. The Sabin vaccine is more effective but can–rarely–lead to actual cases of polio in those who change the diapers of infants who have received the live Sabin vaccine. However, no such cases occurred during the 1962 Cuban anti-polio campaign. There have been no deaths from polio in Cuba since 1962, and but 10 cases of polio, 1963–1989, in children who were somehow missed in the repeated sweep of island-wide polio vaccination campaigns (Stusser, 2013, p. 378; Thomas, 2016, p. 192; Whiteford & Branch, 2008, pp. 69–74).

Another victory has come in the battle against malaria. Before the Revolution, one in three Cuban people was infected with malaria. But by 2010, according to the PAHO, the nation suffered just seven cases of malaria, compared to the 650,000 cases in the Americas as a whole. These days the few cases of malaria found on the island are in rural eastern districts, and are of the less deadly vivax form of the disease.

The Cuban Revolution first started its anti-malaria campaign in 1959, just one month after Castro’s victory, and by 1962, it had lowered the incidence to just 50 cases of malaria for every 1,000 people. 1967 was the last year in which a malaria epidemic was recorded in Cuba. In 1973, the WHO declared the island to be completely free of malaria (Pérez, 1988, p. 364; Thomas, 2016, p. 193; Whiteford & Branch, 2008, pp. 66–67).

By the late 1980s and into the early 1990s, Cuba’s public health and vaccination efforts had brought great victories, with the elimination of polio (which previously had afflicted 1,162 in the decade 1957–1967), tetanus (eliminated in 1972), diphtheria (eradication in 1979), measles (eliminated in 1993, even as thousands still contract the disease each year in Latin America), whooping cough (over a thousand cases in Cuba in 1970 but near-total eradication in 1996), rubella (the last case in 1995), and the near eradication of typhoid fever. Before the Revolution, more than one in ten Cubans suffered from tuberculosis, but today TB has been all but eliminated (because the BCG tuberculosis vaccination is only partially effective, Cuba still suffers 35–40 deaths from the disease each year). Cuban vaccine coverage is stronger than most other regions in the world. Today, the USA has an overall childhood vaccination rate of 70 percent, while in Cuba, it is 99 percent (Cuba, 2015, pp. 40, 95–96; Cuba, n.d., p. 8; Erwin & Bialek, 2015, p. 1509; Huish, 2013, p. 36; Mesa-Lago, 2009, p. 378; Sixto, 2002, p. 333; Thomas, 2016, pp. 192–193; Whiteford & Branch, 2008, pp. 13, 26, 28, 30, 63, 114).

Dengue fever control has been a special challenge for Cuba and the Caribbean. Dengue is a vector-borne illness, spread by the aëdes mosquito. As the global climate has warmed in recent years, this has opened up more aëdes mosquito breeding areas, bringing with it many more cases of dengue or “breakbone” fever. Every year, there are 50–100 million cases of dengue worldwide, resulting in some 24,000 deaths. There are several types of dengue, and those who have suffered previously from one strain of dengue are especially at risk of death if they contract one of the other forms.

Dengue has hit nearly all of Latin American countries in recent years, leaving only Chile and Uruguay untouched. There have been several outbreaks of dengue in Cuba, in 1977, with some 400,000 cases but without yet the deadly hemorrhagic form; in 1981, the worst episode, with 158 deaths in Cuba; in 1997, confined to the city of Santiago in western Cuba, with 3,012 people infected and 12 deaths; a lesser outbreak in 2001 in Havana and Santiago; and in 2006–2007 in Santiago, leading to 13,147 cases and eight deaths. Since then, there have been no deaths from dengue in Cuba: in 2009, 70 cases and no deaths, whereas in Latin America as a whole, there were that year 1.1 million cases and 598 deaths; in 2011, over one million cases of dengue fever in Latin America and the Caribbean, but none that year in Cuba; in 2013, 1,430 cases in Cuba and no deaths, while in Latin America as a whole, there were 2.4 million cases and 1,318 deaths; in 2014, 2,522 cases and no deaths in Cuba, while in Latin America as a whole, there were 1.2 million cases and 798 deaths; and in 2015 in Cuba, 1,641 cases and no deaths, while in Latin America as a whole, there were 2.3 million cases and 1,181 deaths. But Cuba’s gains against dengue remain at risk, with reinfection a constant threat. Cuba remains an island surrounded by a sea of dengue (Macías Miranda et al., 2013, p. 3044; PAHO, 2010, 2014, 2015, 2016; Saker, Lee, & Cannito, 2007, p. 30; Whiteford & Branch, 2008, pp. 75–77).

In 1981, when dengue hit nearly all of the Caribbean, Cuba began to build an effective response, using the public health models it had previously deployed in attacking polio and malaria. When dengue surged in the Caribbean region in 2002 and 2003, Cuba launched a massive campaign to remove all potential breeding sites for the disease-carrying aëdes mosquitoes. Cuba became, and remains, very aggressive about mosquito abatement, with public health inspectors aided by the army, neighborhood organizations, and even school children helping to identify potential breeding sites. The most dangerous mosquito vector, the aëdes egypti, is also responsible for spreading Zika, chikungunya, and yellow fever, propagating by the millions in urban settings near human dwellings. Cuba has settled on a highly intrusive approach, if a highly effective one, with public sanitation workers and their auxiliaries marching right into people’s backyards, tipping over all the containers holding standing water, spraying and splashing about oily-smelling pesticide. Those people who try to chase off the health inspectors and the auxiliary brigades can receive heavy fines. But overall, this approach has worked. Cuba has suffered just 62 reported cases of chikungunya, all but two imported. Zika first arrived in Cuba in early in 2016, with the mass spraying campaign beginning even before the first case of Zika was reported. By the end of the year, Cuba had suffered 187 confirmed cases. The two pregnant women who were diagnosed with Zika elected to have abortions. By mid-2016, Honduras, by way of comparison, had 30,087 confirmed cases of Zika. All told, Cuba has been the least afflicted nation in the region from all of these mosquito-borne diseases (Cuba, 2015, p. 13; Kahn, 2016; Macías Miranda et al., 2013, p. 3044; PAHO, 2017; Reardon, 2016; Spiegel & Yassi, 2004, p. 101; Waters, 2016; Weissenstein, 2016; Whiteford & Branch, 2008, pp. 25, 76).

Some critics seem to not to have noticed this evidence. Mary O’Grady, writing in the Wall Street Journal, reported in 2014 that Cuba was “in the midst of persistent dengue and cholera outbreaks on the island” (O’Grady, 2014). But as noted earlier, since the 2006–2007 outbreak of dengue in Cuba, there have been no deaths from this disease on the island. Likewise, in 2011, the PAHO reported that while nearly 3,000 people in the region had died of cholera since 2010, there were no cases of cholera in Cuba. Actually, Cuba has today the lowest rate of infectious disease of any Latin American nation. In 1970, infectious disease accounted for 7.2 percent of all deaths in Cuba; by 2014, it was 1.3 percent, mostly due to influenza, a disease that also haunts the developed world (Cuba, 2015, pp. 76, 83; Maceira, n.d.; PAHO, 2012; Whiteford & Branch, 2008, p. 77).

Before the Revolution, the leading killers in Cuba were generally infectious ones, malaria, tuberculosis, among others. Nowadays, the leading killers in Cuba, accounting for roughly three-quarters of all deaths, are the same ones found in the developed world, that is, long-term debilitating diseases, such as heart disease; strokes; cancer; and one remaining infectious killer, influenza (especially among the elderly). By way of comparison, in the USA infectious diseases accounted for 30 percent of all deaths in 1900, but only 3 percent in 2000. Cuba is similar to the USA in this regard, whereas the poorest nations of the world are more like the USA of 1900. When the world agreed to the Millennium Goals for disease reduction by the year 2000, Cuba had actually already realized all of these objectives in advance. The one other leading cause of death in Cuba is accidents, especially traffic collisions. Still, Cubans suffer fewer traffic accidents because, compared to other places, there are fewer cars. And because Cuba has neither an illegal drug problem nor the wide presence of guns, homicide rates are very low: only Canada and Chile in the hemisphere have lower homicide rates (Cuba, n.d., p. 9; McMurray, 2004, p. 93; Vick, 2015, p. 34; Whiteford & Branch, 2008, pp. 81, 82, 104).

Cubans have suffered from HIV/AIDS far less than the people in other nations. Although Cubans infected with HIV/AIDS were previously discriminated against, especially in the years from 1986 to 1989, this is no longer the case. In the years from 1986 to 1994, patients in Cuba infected with HIV/AIDS were forcibly removed to quarantines. Cuba was the only nation in the world to open such facilities. It is likely that HIV/AIDS first came to Cuba with the returning military personnel previously stationed in Africa, possibly infected by sex trade workers, although the exact route of entry to Cuba is unknown. One of the first steps Fidel Castro took was to throw out all blood previously collected for transfusions, due to the potential risk of HIV infections. Because most of the HIV/AIDS victims were military members, it was easier to order them to report to facilities where they would be quarantined. About 10,000 people were held in the 14 sanatoriums at the height of their operation. Patients could leave the sanitariums, but they had to be accompanied by staff member at all times. Many gay Cubans fled the islands, horrified by the aggressive anti-gay approach of Fidel Castro and the Cuban government. Yet by 2003, roughly half of Cuba’s HIV/AIDS victims still lived in these facilities, electing to stay on voluntarily in the remaining three sanitariums.

Cuba has today the lowest incidence rate of HIV/AIDS in the Caribbean and indeed one of the lowest rates in the world. Patients receive free medicines to control the disease, the antiretrovirals produced in Cuban laboratories. Today, Cuba sees about 125 new HIV cases per year, but there is no longer any cases of mother-to-child transmission of HIV in Cuba. Since 2008, there have been annual marches against homophobia, and beginning in 2013, workplace discrimination due to sexual orientation became illegal. Today, the Cuban healthcare system will pay the full cost of gender reassignment surgery (de Mayo, 2017; Sweig, 2012, p. 264; Whiteford & Branch, 2008, pp. 77–80).

Generational Shift in Cuba: An Aging Population Profile

In Cuba today, two of three people were born after Fidel Castro took power. As Cuba scholar William LeoGrande notes, with time “ideological ardour cools and the young take the Revolution’s accomplishments for granted, seeing only its failures” (LeoGrande, 2015, p. 401). The graying of the Cuba population has been brought in part by a decline in fertility. In Cuba, in 1961, the fertility rate (the number of children born per woman) was 4.36, but by 2012, this rate dropped to just 1.69. This is an extraordinarily low number. In Africa, the rate is today 4.5. Even Europe’s fertility rate, at 1.8, is higher than that of Cuba (Cuba, 2015, p. 23; Gran Alvarez et al., 2013, p. 825; Whiteford & Branch, 2008, p. 34).

Cuba’s birth rates (the number of live births per 1,000 people) show a similar trend. In 1963, the Cuban birth rate was 35.1, but by 2006, it had fallen to 9.9. Part of this is explained by the fact that in Cuba, abortion is free and available on demand. The practice is common; at least a third of Cuban pregnancies end with an abortion, a higher rate than anywhere else in the world. At points in the 1980s, nearly half of pregnancies were terminated with abortion.

In Cuba, women who are pregnant routinely have their fetuses studied for genetic problems and undergo tests themselves for hypertension, diabetes, or other issues. Women who present with serious health issues for themselves or for their fetus are strongly advised or even pressured into having an abortion. So routinized is the practice in Cuba that because abortion is illegal nearly everywhere else in Latin America, many middle-class and rich Latin American women travel to Cuba to terminate unwanted pregnancies (Garrett, 2010, pp. 61–73; Gran Alvarez et al., 2013, pp. 825, 830; Sixto, 2002, p. 338; Whiteford & Branch, 2008, p. 55). Cuba also has the second highest percentage of women using birth control in Latin America, second only to Costa Rica. In Costa Rica, sterilization is the most common method, while in Cuba, intrauterine devices (IUDs) are the most practiced method of birth control (Howse, 2014, p. 1).

Under the Revolution, Cuba has enjoyed some meaningful progress in lowering maternal mortality rates (the number of pregnancy or delivery-related deaths per 100,000 live births per year). In 1955, the maternal mortality rate in Cuba was 145, and in 1958, it was 125. According to the PAHO, however, by 2012, Cuba showed a maternal mortality rate of 41, better than the rates of 56–68 in Brazil or 120–158 in Guatemala, although not as good as 9–12 in Canada or 21 in the USA (Garrett, 2010, pp. 61–73; Gran Alvarez et al., 2013, p. 830; PAHO, 2012; Sixto, 2002, pp. 334, 338; Stusser, 2011, p. 224; Whiteford & Branch, 2008, p. 26). According to data provided by the British medical journal, The Lancet, in 2013, the maternal mortality rate in Cuba had fallen to 39.8 per 100,000 live births, compared to 54.0 in Mexico, and 58.7 in Brazil (The Lancet, 2015, p. 2). Cuba offers a 21-month program of care for expectant mothers and newborns, continuing beyond the child’s first year of life. In Cuba, nearly all births are attended by trained medical personnel, whereas in Nicaragua, by way of comparison, only three-quarters are attended by trained medical personnel, and in Guatemala, only half are attended by trained medical personnel (PAHO, 2012). Cuba operates maternity centers across the island especially for women with complications in their pregnancies. The rise of the number of maternity homes actually took off during the special period, as Cuba sought in these very difficult economic times to protect its most vulnerable. The number of birthing centers rose from 148 in 1989 to 258 by 2000. Today, women commonly move into a birthing center in the days just before delivery, even when there are no complications in the pregnancy (De Vos et al., 2012, p. 472; Kath, 2006, p. 358).

Overall, with fewer babies being born, fewer people dying of infectious illnesses, and with many working-age people leaving the island, the Cuban population actually stopped growing and started to contract in 2010. Today, Cuba has the oldest population profile of any Latin American nation. By the year 2050, the Cuban population will probably have fallen to just over 8 million, down from the over 11 million living on the island today. By that date, it is likely that Cuba will have one of the oldest populations of any nation in the world (Díaz-Briquets, 2015, pp. 3, 7; Scheye, 2009, p. 385). And because men in Cuba commonly retire at about age 65 and women at age 55 emigration may actually be good for the Cuban economy, reducing the need for job creation and easing housing shortages, while supplying scare foreign currency in remittances in return. Cuba has opened countless community centers for the elderly where they can receive medical care, companionship, and meals during the day, while their younger family members are off at work or school (Díaz-Briquets, 2015, p. 5; Sixto, 2002, p. 338; Whiteford & Branch, 2008, pp. 31, 49).

Infant Mortality Rates

Significant improvement in the infant mortality rate stands as perhaps the great achievement of the Revolution. The Cuban infant mortality rate (the number of deaths, age 0 to 1, per 1,000 live births, per year) was 33.4 in 1958, rising after the Revolution to 46.7 in 1969 as nearly half of Cuba’s 6,912 doctors left the island. But beginning in the 1970s, Cuba embarked on a determined effort to reduce its infant mortality rate. By mid-decade, Cuba had brought down its infant mortality rate to 28, the lowest level anywhere in Latin America at the time. By 1984, the Cuban infant mortality rate had fallen to 15, a level lower than most of the developing world in that decade.

By 2008, Cuba’s infant mortality rate stood at 5.3 per 1,000 live births per year, compared to 22 in all Latin America. By 2013, Cuba’s rate had dropped to 4.70, lower than the rate found in the USA, 6.17. This is an unbelievable achievement, especially when one considers that other nations spend much more on healthcare. For example, Mexico and Brazil, which both devote much more per capita on healthcare, have much worse infant mortality rates than does Cuba, with Mexico at 15 and Brazil at 17.

For Cuba similar gains have come in under-five (or childhood) mortality. In 1970, Cuba’s childhood mortality rate was nearly 40 per 1,000 live births per year. But by 2004, the childhood mortality rate in Cuba was 11 for males and 8 for females, compared to Bolivia, with roughly the same per capita income, at 84 for boys and 76 for girls. By 2013, Cuba’s childhood mortality rate stood at 5.7, not as good as Japan at 3, but better than the USA at 6.6 and better than Latin America as a whole, 17 (Cuba, 2015, p. 47; Economist Intelligence Unit, 2013; Erwin & Bialek, 2015, p. 1510; Maceira, n.d.; PAHO, 2012; Sixto, 2002, pp. 334–336; Spiegel & Yassi, 2004, p. 86; Stusser, 2011, p. 226; Wang et al., 2014, pp. 957, 962–963, 967; Whiteford & Branch, 2008, pp. 26, 82).

Cuba focused its efforts on providing rehydration for infants suffering diarrhea, the leading cause of infant death around the developing world. Opening rural rehydration clinics, in Cuba deaths from infant diarrhea swiftly fell from 25.8 per 100,000 child per year in 1965 to 3.1 in 1980. In Cuba today, all infants up to one year old must have their mother take them to visit a doctor 15 times per year, those children between one year and four years of age have 12 required visits, and then up to age 14 usually have 11 more required visits with a pediatrician. Children in Cuba will have had 38 visits with a doctor by age 14, whereas the average child in the USA will have had 22 visits with a doctor by age 20 (Whiteford & Branch, 2008, pp. 53–55).

It could well be that Cuba is not accurately reporting its actual infant mortality rate, counting those infants born alive but who die shortly after birth as stillborn. Cuba reports the highest stillborn rate, or infant deaths counted as stillborn, of any nation in Latin America, by far. Cuba reports more late fetal deaths as a proportion of all birth outcomes than any other nation in the world, with a rate about three times higher than the average. Looking at this data, researcher Robert M. Gonzalez of the University of North Carolina, Chapel Hill, concluded that there is “misreporting by Cuban health authorities” (Gonzalez, 2015, pp. 21, 29, 30). This misreporting could represent an honest difference of opinion over what constitutes a late fetal death and what should be counted as the death of newborn child. However, it could also represent an effort to distort the data to make Cuba’s infant mortality rate look better than it actually is. Nevertheless, even if there were no miscounting, Cuba’s infant mortality rate would still be extraordinarily good (Stusser, 2011, p. 224).

Cuban Medical Internationalism

Another significant achievement of the Revolution is Cuba’s commitment to medical internationalism, sending medical missions all over the world, seeking to help fellow developing nations. Cuba makes an oversized contribution in this regard, its international medical assistance greater than that offered by all the developed nations of the world combined. Cuba has posted over 130,000 medical personnel in 107 nations. By 2011, one of every 241 Cubans was serving abroad in a foreign aid program, either in medical or in other social outreach initiatives. By way of comparison, in the same year, one of every 23,372 Americans was so involved. Estimates place the number of lives saved by Cuban medical internationalism at over two million people (Erisman, 2012, pp. 272–273; Feinsilver, 2010, pp. 92, 96; Gorry & Keck, 2015, p. 413; Kirk, 2009, p. 283; 2012, p. 78).

Cuban began the practice of medical internationalism right after the triumph of the Revolution. In 1960, Cuba sent doctors to Chile to provide disaster relief following the world’s most severe earthquake, the 9.5 level Valdivia quake. Then, in 1963, Fidel Castro sent a brigade of doctors to help in Algeria during the midst of their war for independence. Cuba’s international commitment continue to grow, and by the mid-1980s, it was producing doctors specifically to staff its overseas deployments. The number of Cuban health professionals serving abroad rose from 5,000 in 2003 to 25,000 in 2005, rising to over 40,000 by 2007. In 2013, Brazil’s President Dilma Rousseff’s brought in some 7,400 Cuban doctors to tend to people in poor regions, this after her efforts to attract Brazil physicians to serve in these zones failed to fill even a fraction of the needed postings. In Bolivia, Cuba has sent doctors and other medical professionals, opening over 500 clinics in heretofore unserved zones, all under the auspices of the Alianza Bolivariana para los Pueblos de Nuestra América, the Bolivarian Alliance for the Peoples of Our America or ALBA, an association of left-oriented nations of Latin America. Under ALBA, Cuba has sent doctors all over South America. Cuba today also has medical brigades in over 30 nations in Africa, many in the Pacific islands, and sends many other professionals abroad, especially teachers to assist in literacy campaigns in Spanish-speaking nations.

Several key efforts stand out in Cuba’s commitment to helping with medical care around the world. In 1986, Cuba provided great assistance after the Chernobyl nuclear meltdown in the Ukraine, transferring patients to Cuba for continuing treatment, including over 24,000 children, all covered free of charge. In 1998, after Hurricane Mitch hit Honduras, Guatemala, and Nicaragua, killing some 30,000 people, Cuba immediately sent 1,000 doctors into the region. At the time, the Honduran infant mortality rate was 250 along the impoverished Atlantic coast region. Cuban doctors stayed in Honduras long after the hurricane damage had been handled, working to successfully lower the infant mortality rate in the region to 20. As scholar John Kirk notes, “where Cuban medical staff work …, infant mortality rates … drop … dramatically” (Kirk, 2009, p. 278). When a horrific earthquake hit Haiti in 2010, Cuba was ready with 344 health professionals already serving in the nation before the quake hit; at the time, there were more Cuban doctors than Haitian doctors in the Haitian countryside. Cuba made the largest commitment of any nation to assist the devastated nation, before, during, and staying long after the disaster (Castro, Melluish, & Lorenzo, 2014, pp. 596–597; De Vos et al., 2008, p. 288; Feinsilver, 2010, pp. 87, 89; Huish, 2013, p. 4; Kirk, 2012, pp. 78, 81; Lamrani, 2012, pp. 351, 353; Sabo, 2014; Scheye, 2009, p. 385; Werlau, 2010, pp. 143, 145; 2013, pp. 58, 63; Whiteford & Branch, 2008, p. 13).

Cuba’s largest overseas presence has been in Venezuela, where roughly 31,000 Cuban healthcare professionals have been working in 6,500 community clinics. Cuban doctors arrived initially in December 1999 to help the President Hugo Chávez administration deal with heavy mudslides that had killed some 20,000 people. But after providing disaster relief, Chávez and Castro worked out a deal to use Cuban doctors in Venezuela’s long-neglected poorer districts. Usually, the Cuban doctors serve two years in Venezuela’s Misión Barrio Adentro (or “Into the Community Mission”) program, a Chávez initiative dating from 2003 that treats patients in low-income areas. The Cuban doctors and healthcare professionals have served neighborhoods that nearly never had doctors present before. Whereas Venezuela could offer only one doctor for every 17,300 people before Barrio Adentro, with the arrival of the Cuban doctors by 2008, there is now one doctor for every 3,400 Venezuelans. Cuban doctors train Venezuelan medical students, who, upon graduation, then step in to serve in the poorer neighborhoods. Cuba and Venezuela in 2005 together launched the Nuevo Program de Formación de Médicos Latinoamericanos (New Program for the Development of Latin American Doctors, or NPFML), with a commitment to educate 100,000 new doctors, for free, over the decade. By 2011, they had already trained 50,000 healthcare providers (Castro et al., 2014, p. 596; Hartmann, 2016, p. 2147; Kirk, 2009, pp. 281–282; 2012, p. 81; Werlau, 2010, p. 146; 2013, p. 59).

Another Cuban initiative, Operación Milagro (Operation Miracle), started in 2004 with support from Venezuela. Venezuela was in the midst of a literacy campaign but was discovering that many people could not see well enough to read. Operation Miracle was therefore created to provide free eye surgery to those who had lost most or all of their vision. At first, the patients were flown to Havana, but now Cuba operates 61 clinics in several Latin American nations and across the world. Over two million people have had their sight restored by Operación Milagro. One Bolivian, Mario Terán, the soldier who killed Cuban hero Che Guevara in 1967, had his cataracts successfully operated on, free of charge, under Operation Miracle, something certainly in keeping with Che’s philosophy of medical care as a basic human right. Not all support this program, however, as WikiLeaks documents from the US Department of State have revealed that the USA sought to pressure Mexico to cut off its cooperation with the Operación Milagro program (Feinsilver, 2010, p. 91; Huish, 2013, pp. 57–58; Kirk, 2009, p. 276; 2012, p. 89; Lamrani, 2012, pp. 354, 358).

Cuban medical assistance is substantially different than that usually offered by other nations. In disaster relief situations, many countries will respond at the time of crisis but then will nearly always leave after a few weeks. Cuban help is different. Cuban physicians and healthcare professionals may well be on hand even before any crisis, deployed as a medical internationalism health brigade. Moreover, Cuba has made a commitment to offer not just urgent care but to stay on as long as the host nation wants them to do so, moving from providing care to helping with longer-range public health needs and then working to train local doctors who work side by side with the Cuban physicians until the point arrives when the Cuban doctors are no longer needed.

Too often, international healthcare initiatives focus on one affliction, worthy programs certainly, but ones that too often can result in literally stepping over other dire public healthcare needs. Because Cuban healthcare professionals focus on prevention, when their brigades come to host nations they direct their attention to the wide array of public healthcare needs, not just one high-profile disease. Moreover, the politics of the host nation is not considered in the deployment of Cuban doctors; if the doctors are welcomed, they come, even if the nation is governed by right-wing leaders or even if the nation is a foreign policy opponent of Cuba (Castro et al., 2014, p. 596).

Cuban doctors abroad are paid by the Cuban government with the host country picking up the cost of airfare, room and board, and sometimes providing an additional salary augmentation. After Cuban doctors complete their two-year service abroad, they receive a bonus from the Cuban government, provided they return home to collect it. The doctors abroad may also purchase consumer goods that are hard to find in Cuba, permitted to ship three large boxes home each year for free (Feinsilver, 2010, p. 94; Werlau, 2010, pp. 149–150).

The arrival of Cuban doctors has sometimes met opposition by establishment medical associations in some host nations. For example, after Hurricane Mitch, local Honduran doctors and the College of Physicians in Tegucigalpa organized a protest seeking to drive out the Cuban doctors, seeing unfair market competition in the free delivery of medical services. In Trinidad and Tobago, Cuban doctors who came in to provide care during a strike by healthcare providers were heckled as scabs. Still, it is hard to agree with the view that Cuba doctors compete against local doctors; the Cubans work in the poor areas where the local doctors had nearly always refused to go. Where Cuba sends it doctors, it recruits locals from poor neighborhoods to go to medical school, either in Cuba or in facilities opened up by Cuba in the host nation. By 2012, Cuban had opened 12 medical schools in developing nations around the world. By turning its medical missions around the world from a brief crisis-driven experience into an opportunity for launching doctor training programs in the host nations, Cuba is, as analyst John Kirk has put it, turning “brain drain” into “brain gain” for these participating nations (Feinsilver, 2010, p. 95; Kirk, 2009, p. 284; 2012, p. 80).

Some in Cuba have questioned the wisdom of sending so many doctors abroad. Complaints from Cuban patients have emerged, with some arguing that waiting times at clinics have increased with the placement of so many Cuban doctors overseas. With many doctors abroad, the workload per doctor in Cuba rose from around 600 to as many as 1,500 patients. By 2008, a quarter of Cuban physicians were working abroad, with nearly 37,000 health professions stationed in some 72 nations. By 2012, over 41,000 medical workers were abroad, providing care in 68 countries. Some reports concluded that a third or as many as half of all Cuban doctors had been shipped off, sent to earn money for the Revolution, if not earning enough for themselves or their families. Serious money is involved: more than a quarter of Cuba’s export earnings comes from income gained through its medical internationalism programs. Today, the largest share of Cuba’s export earnings come from its medical missions abroad.

Part of what makes foreign medical service so attractive to many Cuban physicians is that they are paid so poorly in Cuba. Most find that they have to take on extra work driving cabs or working in the tourism sector. Still, as one Cuban doctor put it, “no Cuban health professional … decides to pursue a career in medicine for reasons of personal material gain because … this is not what you will get” (Kath, 2006, p. 353). Given the low pay and endless hours, some physicians have given up and dropped the profession entirely. Many others have chosen to leave their families for two years to serve in foreign medical missions where the pay is substantially better, sending the extra cash home. Nevertheless, even for sending so many doctors abroad, Cuba continued to have the best doctor-to-patient ratio of any nation in the world. Even the US Department of State admitted that Cuba has “an over-surplus of physicians,” clearly more than enough to spare for its medical internationalism initiatives (De Vos et al., 2008, p. 288; Feinsilver, 2010, p. 98; Huish, 2013, pp. 9, 45; Kirk, 2009, p. 280; 2012, pp. 78–79; Mesa-Lago, 2009, p. 378; Pérez-Stable, 2010, p. 55; Werlau, 2013, p. 60).

Another concern is that some of the doctors in the Cuban overseas medical mission program have skipped out on their foreign deployment, in Venezuela or elsewhere, complaining of exploitation and sometimes dangerous neighborhoods where they were assigned to live and work. By 2010, 68 Cuban doctors had died during the seven years of medical postings in Venezuela. Some of these deaths, perhaps most of them, were a part of the high incidence of violent crime in the poorer neighborhoods of Caracas, today the city in the world with the highest homicide rate. Mary O’Grady, writing in the pages of the Wall Street Journal, informed her readers that over 3,000 Cuban have defected, taking advantage of a special visa program the USA offers for those Cuban healthcare professionals working abroad, the Cuban Medical Professional Parole Program (since 2006). O’Grady, relying solely on the testimony of defectors, argued that these medical professionals are part of “Cuba’s slave trade in doctors” (O’Grady, 2014).

What critics like O’Grady do not seem to adequately note, however, is that over 97 percent of the Cuban doctors serving abroad are not lured out of the program. Moreover, those doctors who have left have nearly always receive a very poor welcome in the USA. Indeed, most of the defectors have found it all but impossible to win acceptance of their Cuban medical credentials in the USA. The Cuban training is different, focusing much more on prevention, not on the curative model taught in US medical schools. Most Cuban-trained doctors also often find that they do not have the English language skills needed to pass the four US medical board exams. As a result, most Cuban doctor defectors will never end up practicing medicine in the USA, or if they do, it will be after retraining as a nurse. Another, more careful estimate of the defections is offered by researcher Robert Huish, who found that by 2007, some 420 doctors had left the program or just around 3 percent of those stationed overseas. Other estimates put the number of defections beneath 2 percent. Many Cuban doctors who leave their foreign postings and apply for fast-track entry into the USA may be denied entry into the USA if they were previously a member of the Cuban Communist Party or any of its youth affiliates. However, joining these organizations are common steps in normal career paths in Cuba. This means that many doctors who are coaxed into defecting are then refused admission into the USA, while stilling facing punishment in Cuba for abandoning their post if they return home. These individuals are left stranded where they were stationed abroad, unwelcome in the USA and not wanted back home in Cuba. President Obama ended the Cuban Medical Professional Parole program in January of 2017, and its present fate is uncertain (Erisman, 2012, pp. 279–282; Feinsilver, 2010, pp. 95–96; Garrett, 2010, pp. 61–73; Huish, 2013, pp. 69, 110; Werlau, 2010, p. 151).

ELAM: Cuba’s Latin American Medical School

In 1999, Cuba founded the Latin American Medical School (Escuela Latinoamericana de Medicina, ELAM) in Havana, growing out of Cuba’s experience of providing medical assistance in the wake of Hurricane Mitch in Central America. The idea was to train doctors from poor areas in Latin America, especially rural zones, physicians who would return to their homes and practice medicine after their six years of training with ELAM. ELAM offers medical training to students from around the developing world, with students from over 50 countries attending. Students even came from the USA for a time, a practice that ended in 2013. Built on the grounds of the old naval academy just outside of Havana, ELAM is the largest medical school in the world (Huish, 2009, pp. 301–302; 2013, pp. 85, 111; Kirk, 2009, p. 279).

Most medical schools in the developing world train doctors in practices that are better suited to the high-cost curative practices set up in the wealthier nations. Often this means that developing nations spend scare resources on training doctors only to see them pack up and leave for the developed world as soon as their education is completed. This is not the case with ELAM, which focuses on preventive and community care. Three of four ELAM students come from poorer families, and the training they receive at ELAM focuses on the health risks that grow out of poverty and poor living conditions, the situations that the ELAM graduates must face when they return to their home communities. The instruction for low-income students is free. All that is asked of students is a moral commitment that after graduation, they to return to their homeland and serve patients in the poor communities from which they came (Huish, 2009, pp. 301–302; 2013, pp. 86, 97; Labonte, 2004, p. 61).

The six years of training medical students receive at ELAM focuses on public health and specific regional health risks, especially those born of poverty. As one Mexican student puts it, “you study the health of the community, before [you study] the health of the individual” (Huish, 2000, p. 556). After two years at ELAM, students move on to train at one of the 23 medical schools on the island. ELAM graduates 3,000–4,000 doctors each year, usually handling about 9,000–10,000 students a year, peaking at 11,000 students in 2005, and generally taking in 1,400 new students each year. Cuba also operates another medical school in the eastern city of Santiago for French-speaking students, training about 500 students at any given time. Counting also the medical schools operated by Cuba abroad, the number of medical students in training has reached 50,000 a year (Erisman, 2012, p. 274; Flegel, 2009, p. 305; Huish, 2013, pp. 9, 84–85; Kirk, 2009, p. 280; 2012, pp. 79–80; Werlau, 2013, p. 61).

There is no charge of any type for most of the medical students, indeed they even receive a small salary. Tuition is only levied on those students who come from more affluent nations. Conditions at ELAM can be demanding, with cramped housing and low-budget meals, and the hours of labor are endless. But after graduation, more than half of the students do return to their home communities and practice medicine, while most of the others stay on in Cuba to learn a specialty (Huish, 2013, pp. 68, 81).

There has been some criticism of Cuban medical internationalism, with some of the establishment medical associations in the receiving nations standing in opposition to the ELAM program, refusing to recognize the credentials of doctors trained in Cuba. Perú, Antigua, Argentina, Guatemala, and Brazil have at points refused to recognize the credentials of ELAM graduates to practice of medicine in their nation.

The ELAM training is indeed different. Medical students at ELAM do not learn how to operate the latest and more expensive equipment and receive less instruction in curative methods. ELAM graduates receive training which emphasizes prevention, learning how to make do without expensive equipment or even some medicines, for ELAM believes that these are precisely the conditions that their graduates will encounter when they return home to provide medical care in remote and impoverished regions (Badawi, 2004, p. 80; Huish, 2009, p. 303; Kirk, 2012, p. 80).

Biotechnology Sector in Cuba

Shortly after the Revolution, Fidel Castro’s demanded that the foreign-owned pharmaceutical companies in Cuba lower drug prices. When the companies refused, Castro seized the enterprises and all their assets. From this beginning, and with gathering speed in the 1980s, biotechnology became an important sector of economic achievement and scientific advance for the Cuban government (Cueto & Palmer, 2015, p. 210; Scheye, 2009, p. 385).

In May 2002, US Undersecretary of State for Arms Control, John Bolton, announced that, “the United States believes that Cuba has at least a limited offensive biological warfare and research and development effort.” “Cuba has provided dual-use biotechnology to other rogue states,” the undersecretary believed (Pérez-Stable, 2010, p. 50).

But Bolton’s views were not grounded in fact; the Cuban biotech industry is entirely focused on humanitarian and medical purposes. The evidence is overwhelming. Today, there are 58 drug manufacturing facilities in Cuba, making pharmaceutical generics and vaccines. Cuban facilities, including the flagship Carlos J. Finlay Institute, produces 83 percent of the medicines used in the country. Cuba has made particularly significant progress in pioneering the hepatitis B vaccine. Of the 13 vaccines that Cuban children routinely receive, eight are produced in the country. The biotech sector in Cuba responds to the needs identified at the local level, carefully documented in the data collection and reports that are a main focus of healthcare under the Revolution. The Cuban biotech sector focuses on the quantifiable areas of greater human need; it does not have to worry about producing profits, nor, given the Cuban legal landscape, have to worry about being sued. The Cuban biotechnology sector never claims patent rights to its discoveries, making the medicines readily available to needy people around the globe (Gorry & Keck, 2015, p. 414; Huish, 2013, p. 10; Scheye, 2009, pp. 386–387).

Cuba exports pharmaceuticals to 40 nations, sending some 38 different products, all at lower prices than the global pharmaceutical firms. Cuba also manufactures mosquito sprays, used especially in Africa to combat malaria. Cuba’s policies of making pharmaceuticals available to ordinary people in developing nations stands in stark contrast to the approach taken by the for-profit multinational pharmaceutical companies, which routinely seek to secure monopoly rights over drugs they have developed or that they purchased the copyright rights to. There is a desperate global need for medications and vaccinations for use by people in the tropics, generally the poorest regions in the world. The trouble is that only about one of every 1,000 chemical compounds commercialized between 1975 and 1997 was designed to treat or prevent tropical diseases. Multinational drug companies go where the money is, and this is not in selling medicine to people of limited means living in poor nations. Instead, these MNC pharmaceutical companies focus on money-making drugs; selling psychotropic medicines for first world pets has been a good money maker for them lately. Some researchers refer to this as the 10/90 gap, where 90 percent or more of research and development of medicines are directed toward 10 percent or less of the world’s population (or, evidently, their pets). Consequently Cuba’s biotech sector is seeking to address this global healthcare gap, in solidarity with poor people around the world (Kirk, 2012, pp. 85–86; Labonte, 2004, p. 60; Saker et al., 2007, p. 22).

Conclusions

At the Summit of the Americas meeting held in Trinidad and Tobago in April 2009, shortly after Barack Obama took office, the US president commented on the Cuba’s international medical support programs: “It’s a reminder for us in the United States, that if our only interaction with many … [Latin American] countries is drug interdiction, if our only interaction is military, then we may not be developing the connections that can, over time, increase our influence and have a beneficial effect” (Pérez-Stable, 2010, p. 57).

President Obama was right. The evidence shows that Cuba provides an example and inspiration to other less developed nations. It is worth remembering that nearly all infectious diseases have an incubation period of 36 hours or more, that is, a day and a half before a person is too ill to get on a plane and travel. Given this, attacking diseases in remote areas of the world is in the interest of every living person on the planet, not just a problem of poor people living far away. Microbes can travel far and fast; dealing with disease challenges the world over protects the health of all. Good healthcare need not be only available to affluent city dwellers, but it can and must be available to all. We must do this because it is in everyone’s personal self-interest, because it is the smart thing to do, but more, much more, we must do this because it is the right thing to do. We must do so because healthcare is a basic human right for all.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.