Moral medicine: the Cuban way
It is one of the world’s best-kept secrets: an island nation, whose citizens earn on average under $50 a month, has outstripped the high and mighty in extending international medical support to those in dire need. That nation is Cuba. And its conception of healthcare is nothing short of revolutionary.
Cuba currently has more medical personnel serving abroad than all of the wealthy G-8 nations combined. As of April 2012, there were 38,868 Cuban medical professionals working in 66 countries, of whom 15,047 were doctors – about 22 per cent of Cuba’s total number of physicians. To date some 135,000 health workers have participated in medical missions abroad.
John M Kirk
Cubans don’t use the term medical ‘aid’ – which they see as extremely paternalistic. Instead they refer to ‘co-operation’ or ‘collaboration’. Cuban medical teams do not engage in disaster tourism. They are there for the long run: generally working for two-year periods, to be replaced by other Cubans should the need persist.
Their vision is to introduce a sustainable medical system which trains up the local population to play an active part. This approach differs from that employed by well-meaning, but often naive, medical professionals from industrialized nations who drift in and out of poor countries. Because the Cubans live within the communities where they work, they are visible, not only on their daily visits to their patients, but also as they line up at the market for food or get water from the local well. Significantly, too, they do not charge their patients for medical care.
The patient as person
In many ways the approach used by Cuba in its numerous overseas missions mirrors its domestic public health system. First, there is no cost for the patient, since access to healthcare is seen as the most fundamental human right and is embedded in the Cuban Constitution. Cuban medical training insists on solid diagnostic skills, since access to high-tech equipment abroad – from basics such as X-ray machines to scanners and the like – can be extremely limited. Moreover, patients are not seen as suffering from a singular ailment, treatable by a simple prescription: instead they are viewed in the wider bio-psycho-social context.
'We send doctors, not soldiers!' Fidel Castro
El Salvador’s Minister for Public Health María Isabel Rodríguez emphasized this grounded outlook when she spoke with me in 2010: ‘The Cubans treat them [their patients] as individuals, recognizing their human quality, and spending time with them. Their medical treatment is different – the Cuban doctors respect their patients and listen to them.’
Unlike the emphasis in industrialized countries on curative treatment, Cuba’s approach to medical care consistently promotes prevention of diseases. This is, of course, far more cost-effective. When drugs are required, Cuban medicines are often used – Cuba produces some 80 per cent of its own medical products, which are sold at a fraction of the price they would cost elsewhere. (When my daughter was studying in Cuba, she received three injections after a bad peanut reaction – adrenaline, an antihistamine, and dextrose. The cost was $1.25, $0.75 and $0.75 – the price paid by foreigners; for Cubans this would have been free).
The Cuban medical contingents serving abroad spend a tremendous amount of time in basic public education campaigns on healthcare matters. I saw this myself in 2010, when I spent two months with Cuban personnel in El Salvador and Guatemala. They had arrived in November 2009 after tropical Storm Ida had wreaked havoc in El Salvador. After two months of providing emergency medical care in a central field hospital, the Cubans began a series of activities to improve emergency preparedness, and also to show Salvadorians how to help stop diseases such as dengue from spreading. I accompanied teams of Cuban and Salvadorian health promoters to rural communities where they went door-to-door, distributing chemicals to be used in water tanks to kill mosquito larvae, and talking about basic health promotion and hygiene.
‘When I heard the Cubans were participating, I expected something quite different – a form of supervision or control by them,’ one Salvadorian health promoter told me. ‘I did not expect a team in which we were all fully integrated, working side by side as we went door-to-door together advising people about the means of eradicating dengue.’
Finally, the system is based upon medical training in which ethical considerations and the responsibilities of professionals are emphasized far more than in medical schools of the industrialized world. Cuban medical personnel serving abroad go where the need is greatest, and where the host government assigns them responsibilities. The result is that the Cuban system has developed a cost-effective, pragmatic, highly ethical and sustainable system of public healthcare. It is this basic framework which is shared with the host country, and which has been remarkably successful for decades.
Relief before politics
Many people first heard of Cuba’s medical internationalism programme when the country offered 1,500 medical professionals to support the disaster relief effort after Hurricane Katrina pounded New Orleans in 2005. (US President George W Bush rejected the offer.) In fact, Cuba has been sending medical teams abroad since 1960, when an earthquake occurred in Chile. This was followed by a large medical delegation sent to Algeria in 1963 to help the construction of the national healthcare programme following that country’s independence from France.
It is important to note the historical context in which these early medical missions were sent. The revolutionary government headed by Fidel Castro came to power on 1 January 1959 after the authoritarian Batista regime was overthrown. By 1961 almost half of Cuba’s medical personnel had fled, most to Miami; approximately 3,000 were left. Yet despite the pressing situation in Cuba, the government saw the need to provide internationalist support. Since then, medical contingents have been sent around the globe to help in emergency situations – regardless of ideological differences with the host country.
Several hundred Cuban medical personnel are working in Honduras, for example, despite Havana’s protests against the coup which overthrew democratically elected president Zelaya in 2009. Likewise, while Havana condemned the removal of President Fernando Lugo in Paraguay in June 2012, Cuban doctors remain there. Perhaps no greater enemy of the Cuban revolutionary process in the region was Nicaragua’s Anastasio Somoza. Yet when a massive earthquake occurred in Managua in 1972, the Cuban contingent was among the first to arrive. In 1998 the disastrous impact of Hurricane Mitch in Central America (over 20,000 were either killed or declared missing) led to a number of missions. Significantly, Cuba did not have diplomatic relations with the countries that were worst affected, yet did not hesitate in sending large delegations to the affected areas (424 specialists arrived within days, peaking at 2,000). Humanitarian considerations rather than political sympathies remain key to Cuba’s approach.
Since Hurricane Katrina, Cuba has been involved in medical emergencies in many countries, and has formed a special medical contingent (several thousand-strong) to respond to natural emergencies – the Henry Reeve Brigade (named after a US volunteer who had participated in Cuba’s first war of independence from Spain, from 1868 to 1878). This group of specialists trained in disaster medicine has been involved in 12 overseas missions. The largest was to Pakistan, where some 2,250 Cuban personnel worked following a major earthquake.
The most significant involvement was in Haiti. Most people can remember Cuba’s role after the January 2010 earthquake, and its major contribution in stopping a countrywide cholera outbreak. What is often overlooked, however, is that Cuban medical personnel had been working in Haiti since 1998, when Hurricane George wreaked havoc there. Cuba immediately sent 500 medical staff, and when the earthquake struck 12 years later there were still 340 Cubans working throughout the country.
The Cuban contribution to a sustainable public healthcare system is also significant. Cuban medical training has been provided to Haitian students, and by 2011 some 625 had graduated as doctors. Supported by Venezuela and Brazil, Cuba is now engaged in developing a national healthcare system for Haiti.
A major initiative resulted from Cuba’s role in Central America – the foundation in 1999 of the world’s largest medical university, the Latin American School of Medicine (ELAM), in Havana. The national naval academy was converted into a medical school, principally for students from the regions devastated by Hurricane Mitch. The idea was simple – to provide enough medical personnel for the region.
Students were generally selected from impoverished backgrounds, as it was thought that they would have more ‘buy in’ to their local under-served communities than their wealthier peers, and would want to assist after graduation. The plan was to develop a policy of ‘brain gain’ rather than ‘brain drain’, and to have medical support where it was needed – among the poor and in rural areas. Approximately 1,500 students enrol at ELAM each year, and to date over 10,000 doctors, mainly from Latin America and the Caribbean, have graduated following a six-year programme. There are no tuition costs, books are provided for free, and a small allowance is given to the students. There is, however, a basic stipulation: students make a moral commitment to work with the underprivileged and those most in need of medical care after graduation.
Students make a moral commitment to work with the underprivileged after graduation.
From this significant contribution a variety of other medical education initiatives has grown. The largest is in Venezuela, where over 25,000 students are being trained as doctors by Cuban medical professors. The first graduating class of some 8,000 ‘comprehensive community doctors’ (77 per cent of whom are women) finished their training in February 2012. Cuban professors have helped to found medical schools in Yemen, Guyana, Ethiopia, Uganda, Ghana, Gambia, Equatorial Guinea, Haiti, Guinea Bissau and Timor-Leste.
Making the miracle
One of the more recent medical programmes is ‘Operation Miracle’, a successful ophthalmology initiative. This started in 2004 when it was discovered that a major problem facing Cuba’s international literacy programme ‘Yo, sí puedo’ (Yes, I Can...) was that many of the students had vision problems. (This programme has taught basic literacy to some 7 million people in 28 countries, and is in its own right an extraordinary example of South-South co-operation).
The Cuban leadership decided to set up ophthalmology programmes where they were needed. To date, over 2 million people in 34 countries have been treated by Cuban specialists, mainly straightforward procedures for conditions such as cataracts and glaucoma. I visited three of these clinics in Guatemala, and was impressed by the dedication of the Cuban medical staff, who lived in difficult conditions among their patients. Again, all medical services were at no cost to the patients, most of whom could never have afforded the operations in the private sector.
Cuban medical internationalism is a flag-bearer of Cuba’s commitment to accessible and sustainable healthcare, free to all (especially the marginalized). Any one of the initiatives noted here could stand alone as remarkable – together, they are truly exceptional.
Cuba has clearly managed to make an enormous difference in scores of poor countries, and has done so for over five decades, despite its own economic challenges. Cuban medical specialists have saved the lives of millions of people, given millions more the ability to see, trained thousands of doctors from developing countries, performed millions of operations, assisted at over a million births, and continue to provide medical care around the globe – to approximately six times the population of Cuba. All of this, at no cost to patients or students. How can this be possible?
In essence it comes down to political will, combined with a determination to provide support – co-operation – to the world’s impoverished and marginalized populations. For decades this has involved significant sacrifice on the part of Cuba (although financial support from Venezuela in payment for the services of some 30,000 medical personnel in recent years has turned this into a major source of foreign income). It requires great long-term vision, a sense of humanitarian ethics, and a commitment to the wellbeing of others. It means placing value on human capital rather than in the marketplace. Yet these profound policy initiatives spanning over 50 years have largely been ignored by the international media. Sadly, none of the nations of the ‘developed’ world has the humanitarian commitment to pursue this approach – North-South ‘aid’ has yet to learn from South-South co-operation a la cubana.
John M Kirk is Professor of Latin American Studies at Dalhousie University in Canada. He is the author/co-editor of 13 books on Cuba, and for the last seven years has been studying the significance of Cuba’s medical internationalism.
Chris Walker is a postgraduate student in International Development Studies at Dalhousie University researching improving medical accessibility for rural and marginalized populations.