Cuban Medical Internationalism

Following the fall of the authoritarian regime of Fulgencio Bautista in 1959, the post-revolutionary government in Cuba began to reform the country’s health system. They established a system that reflected many of the values of the revolution, including those of social solidarity and aid for those less fortunate (Cueto & Palmer, 2015). One of the main pillars of the health system that exemplified these ideals was the concept of Cuban medical internationalism (CMI). CMI started as a mission to Chile following a major earthquake in 1960 in which Cuban doctors were sent to Chile to offer aid. Although the mission occurred during a period of instability in the Cuban healthcare system—about half of Cuba’s doctors were leaving the island in the wake of the revolution—it gave birth to a widely applauded and generally successful program that provided human resource-based community care on an international scale. (Kirk, 2012; Huish & Kirk, 2007)

As Cuba’s work in international medicine and education became more renowned, Cuba began sending medical brigades to more countries outside of Latin America, beginning with Algeria in 1963 and to Guinea Bissau later in the 1960s (Huish & Kirk, 2007). From there, CMI has grown to include missions to about 70 countries around the world as of 2018. The largest contingent is in Venezuela, with about 30,000 Cuban doctors (Kirk, 2018). Cuba is able to send so many doctors abroad because it has a surplus of doctors at home; even after sending doctors abroad, the country’s doctor-to-patient ratio of 1:159 is still one of the best in the world (Huish & Kirk, 2007). The program generally entails the country sending physicians and health care professionals to underserved areas in the global South, free of charge to the patients that they see (Pérez, 2019). Those who volunteer for the program are paid their usual salary in Cuban currency, plus a small stipend in the local currency of the host country (Blue, 2010). While abroad, these professionals help increase access to health care around the world and frequently help train local providers (Huish & Kirk, 2007). The program is often cited as an exemplary approach to global health that transcends political, ideological, and physical boundaries. However, there is some controversy surrounding the program, including its motivations, how it has been used in Venezuela, and the effects of the program on its participants.

Overall, the program has been remarkably stable. Not only has it withstood instances of worsening diplomatic relationships—for example, Cuba continued to treat patients from the Ukraine even as the Soviet Union collapsed and its relationship with Cuba worsened—missions have been initiated despite ideological differences (Kirk, 2012). Examples of this include delegations sent to Chile under the Christian Democrat Alessandri and to Nicaragua under Somoza Debayle, an outspoken enemy of the Castro Government (Huish & Kirk, 2007). Another important strength of the program is the role it plays in overcoming structural violence and promoting human security in the global South. Structural violence, in this case, is defined by Huish and Spiegel as the “social, economic, cultural, and gender structures that prohibit individuals from meeting their full potential” (Huish & Spiegel, 2008, p. 45), and human security as securing individuals before nation-states, addressing real needs before intangible desires and immediate threats before perceived dangers (Huish & Spiegel, 2008). The program has also been highlighted as a leading example of social justice-oriented South-South cooperation, with particular acclaim given to its cumulative service to over 100 countries and its cooperation with Venezuela’s Barrio Adentro program as particularly impressive (Birn, Muntaner, & Afzal, 2017).

The figure above provides a list of selected countries to which Cuba has sent physicians and other health personnel. This diverse range of countries may provoke the question of what Cuba gets out of this program as host countries are not limited to regional or ideological allies or to oil-rich countries like Venezuela. One theory maintains that the driving force behind the program is the strong emphasis on international cooperation that has been ingrained in Cuba’s foreign policy and government priorities since the revolution. This theory argues that core aspects of internationalism, like cooperation and the sharing of resources, are integrated into everyday Cuban life and as such should not be overlooked as potential motivators for CMI (Kirk, 2015).

Other theories focus on the more material benefits Cuba has received from the program. These benefits include, at one point, 100,000 barrels of petroleum that Cuba received on a daily basis from Venezuela and the program’s historic ability to strengthen Cuba’s positive international relationships and earn recognition from once-hostile countries like Guatemala (Huish and Kirk, 2007; Huish and Spiegel, 2008).

There are also perspectives that view the main goals of the program as centering on economic gain and international recognition, rather than on international aid. Werlau, for example, asserts that the program is aimed at advancing the economic goals of the regime and gaining political influence, prestige, legitimacy, and sympathy abroad. She cites the fact that Cuba does usually receive monetary compensation from host countries, though specific quantities are not publicized, and the early use of healthcare and education to legitimize the revolution as evidence for her claim that CMI goes beyond internationalism (Werlau, 2010).

In addition to ideological criticism raised about CMI, concerns have arisen in light of the recent news (as of 2019) regarding the Barrio Adentro program of Venezuela in which many Cuban doctors have participated. News broke in early 2019 of the exploitation of Cuban doctors, a number of whom said that they had been forced by President Maduro to use the threat of withdrawal of treatment and a variety of other tactics to influence voters in the upcoming election. According to 16 Cuban doctors who worked with the Barrio Adentro program, they were told to tell patients that if they did not vote for Maduro, relations between Venezuela and Cuba would break down and the Cuban doctors would be withdrawn from the country, causing many people to lose their access to healthcare. The doctors who have shared this information have since left the program and are considered deserters by the Cuban government; they cannot return to the country or to their families (Casey, 2019). This news, and Cuba’s rejection of it, highlight some of the weaknesses in the CMI program—that it may be used for political gain and manipulation—and supports some of the criticism of CMI—that the country has shown a preference for helping leftist Presidents such as Maduro (Werlau, 2010; Casey, 2019).

Another critique of the program comes from a largely feminist perspective, and draws attention to the effects the program has on the lives of Cubans themselves. While the CMI program provides a means for health professionals who are largely from marginalized groups and disadvantaged in the Cuban economy to gain material and economic empowerment, it can also severely negatively impact their family life (Blue, 2010). Doctors who participate in the program leave their families behind on the island, meaning that many have to ask other family members or neighbors to take care of their children while they are gone. In addition to being separated for long periods of time from their kids, doctors have also cited strained marriages and divorce as other negative consequences of their time spent with the program (Pérez, 2019).

These critiques of CMI demonstrate that although the program has been widely regarded as an exemplary use of human resource-based, horizontal public health interventions, it is not without its problems. Whether those problems are ideological or functional, it is important to recognize both the successes of the program and its drawbacks, especially when considering how the program has impacted public health in Latin America. There is little doubt that the program has had incredible, long-lasting effects on the health of people living in the global South, and especially in Latin America. In addition, the underlying ideals of the program are widely praised by public health officials, and are frequently compatible with concepts of social medicine that have been prevalent in Latin America for decades. However, it is difficult to ignore the hesitancy of the Cuban government in being fully transparent about the program and its finances, and as more attention is drawn to CMI it is possible that the country will face more criticism in that area.

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Additional Resources

Field, C. (Producer and Director). (2006). ¡Salud! [Motion picture]. USA: New Paradigms.

Huish, R. and Kirk, J. M. (2009). Cuban Medical Internationalism in Africa: The threat of a dangerous example. The Latinamericanist, 53(3), 125–139.

Kirk, J. M. and Erisman, H. (2009). Cuban Medical Internationalism: Origins, evolution, and goals. New York: Palgrave Macmillan.

References

Birn, Anne-Emanuelle, Muntaner, Carles, and Afzal, Zabia. (2017). South-South Cooperation in Health: Bringing in theory, politics, history, and social justice. Cadernos de Saúde Pública, 33(2), 37–52.

Blue, S. A. (2010). Cuban Medical Internationalism: Domestic and International Impacts. Journal of Latin American Geography, 9(1), 31–49.

Casey, N. (2019). ‘It Is Unspeakable’: How Maduro Used Cuban Doctors to Coerce Venezuela Voters. Retrieved from https://www.nytimes.com/2019/03/17/world/americas/venezuela-cuban-doctors.html

Cueto, M. and S. Palmer. (2015). Public Health in Latin America: A History. New York: Cambridge University Press.

Huish, R. and Kirk, J. M. (2007). Cuban Medical Internationalism and the Development of the Latin American School of Medicine. Latin American Perspectives, 34(6), 77–92.

Huish R. and Spiegel, J. (2008). Integrating health and human security into foreign policy: Cuba’s surprising success. International Journal of Cuban Studies, 1(1), 42–53.

Kirk, J. M. (2012). Cuban Medical Internationalism Under Raúl Castro. Bulletin of Latin American Research, 31(1), 77–90.

Kirk, J. M. (2015). Healthcare without Borders. Gainesville: University Press of Florida.

Pérez, J. O. and Reis da Silva, A. L. (2019). Cuban Medical Internationalism through a Feminist Perspective. Contexto Internacional, 41(1), 65–87.

Werlau, M. C. (2010). Cuba-Venezuela Health Diplomacy: The politics of humanitarianism. Annual Proceedings, 20, 143–160.