After the Cuban Revolution, Fidel Castro made health and education a priority. In 1959 he said “I invite everyone who has the vocation to study medicine.” Last year, as well as the 4,800 students from 70 other countries who trained on full scholarships from the Cuban government, 5,600 native Cuban doctors graduated. Britain produces around 8,000 new doctors every year. The population of Cuba is one sixth of ours, so the equivalent figure in Britain would be over 33,000.
What do they do with them all? Many work abroad; they are Cuba’s diplomatic weapon.
In 1960 Castro sent 56 health workers to Algeria on a 14 month assignment. Since then the number of Cuban doctors working overseas has multiplied, and an increasing number of medical students qualify each year to feed the demand. Currently there are around 20,000 Cuban doctors working overseas on long-term projects in 100 countries from Venezuela to Vanuatu. Additionally, Cuba sends teams to every natural disaster. Well, nearly every natural disaster: President Bush declined Castro’s offer of help after Hurricane Katrina.
There are other objectors. When Brazil’s president Dilma Rousseff responded to street protests over dire public services by hiring 4,500 Cuban doctors, local medics criticised their standard of care and tried to discredit their qualifications – unsuccessfully. It’s true that it is difficult to assess their outcomes, but independent evidence from Honduras shows that maternal and infant mortality fell dramatically in areas where Cubans had been working. And the complication rate of Cuba’s Operación Milagro cataract programme appears to be acceptable.
Cuban doctors are sent to remote areas and no-go inner city barrios, where millions of poor people have never seen a doctor because local medics will not work there. Maybe these professionals will be shamed into changing their attitudes by seeing Cuban doctors, many of them from poor backgrounds, many of them black, serving poor communities.
Cuban doctors are sometimes suspected of being covert intelligence agents, though the opportunities must be limited for doctors working in, say, Tuvalu, or for the two who found themselves trapped in Karbala during the Iran-Iraq war and operated day and night for months while the bombs fell.
Tellingly, many countries, international organisations and NGOs have sufficient confidence in Cuba’s health programmes to use them as a funnel for aid money. Norway contributed $2 million for Cuba’s emergency work in Haiti. Pan American Health Organization, which is WHO’s American arm, supports Cuba’s health education work in Latin America. Eighty-five NGOs worldwide have subsidised Cuba’s Comprehensive Health Programs in Africa.
The doctors are the front line of Cuba’s medical diplomacy. They are trained with a service ethic, and they know that someday they will be called upon to serve. It’s also an adventure and a chance to travel, an opportunity unavailable to most Cubans. They earn more while they are overseas, and they’re allowed to send home the sort of consumer goods it’s hard to get in Cuba.
And they may defect. It seems unlikely that many teenagers choose to study medicine because it might offer opportunities to escape, but some doctors do jump ship while they are abroad. It’s impossible to determine how many: probably more than the Cubans admit to but less than the US government, which has in the past offered inducements, hoped. And I don’t know the truth about confiscation of passports and surveillance by ‘minders’.
There are personal costs. It seems you can refuse to go if you have a good reason, but pressure will be applied on you to go next time. And it is hard on families. As a woman who spent five years as a single parent while her ophthalmologist husband worked in Venezuela said, “It’s a sacrifice”.
For the state of Cuba doctors are an export. Disaster relief apart, countries pay the Cuban government for the doctors: 28% of Cuba’s export earnings come from selling medical services. Venezuela’s oil has kept Cuba going for the past fifteen years. Other countries pay on a sliding scale.
Some Cubans grumble when waiting times lengthen because doctors have gone overseas, but most are proud of what their country is doing. The benefits aren’t just financial. Cuba has won the admiration and support of nations around the world. Only the USA, Israel and Palau now support the US economic blockade of Cuba. Brazil and Qatar are investing in big projects in Cuba and other countries are signing bilateral agreements. Symbolic capital is converting into material capital. The prestige will stand Cuba in good stead.
What are the ethics of Cuba’s medical diplomacy? Cubans don’t have much choice about serving overseas. They know that is how they will repay their government for funding their training, just as UK students have to pay back the loan which financed their training. Are their doctors providing international aid and development, or are they an arm of the diplomatic corps, or a quasi-military service? Perhaps a bit of all three. They provide deprived populations with essential medical services. They train local people. They are an advertisement for their country.
How does a nation win hearts and minds? Western military efforts in Afghanistan seem to have failed miserably and the British are withdrawing from Helmand. Drones create enemies. Doctors win friends.
Judith Harvey is the founder of a UK-registered charity, Cuba Medical Link, which enables medical students to go to Cuba for their electives.
Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum and an LMC chair. She started a charity which for nine years enabled medical students to go to Cuba for their electives.
Judith is a long-time supporter of NASGP and has been providing regular articles for The Sessional GP for over 12 years, her reflections ranging widely on practical, ethical and cultural aspects of health and medicine.
Judith has now published all her articles from the NASGP website as a new book Perspectives: A GP reflects on medical practice and, well, just about everything…