From the earliest days of the revolution, efforts to legitimize the Marxist Leninist project centered on free and universal healthcare and education. Real and/or reported achievements, aided by a tight control and manipulation of statistics, together with vigorous propaganda efforts worldwide have created an exceptionally favorable international opinion of Cuba’s universal health and education systems.
Fidel Castro realized early on the value of health diplomacy as a tool to advance his goals internationally. The highest-ranking defector from Cuba’s Armed Forces, General Rafael del Pino, recalls how Fidel Castro explained “humanitarianism” as a political calculation; he was convinced that anyone given free education or medical attention would become an ally of the revolution; in the worst case, they would never become its enemy.1 From the initial success of a medical brigade sent to Algeria in 1960 and teams sent for disaster relief, Cuba began to “export” professionals, mostly in the field of health, for service in the developing world. The concept developed into establishing government-to-government agreements premised on sending Cuban health professionals to provide medical care worldwide at little or no cost to the recipients. It was strategically brilliant—while earning hard currency to advance the economic goals of the regime, they gain political influence, prestige, legitimacy, sympathy, and support for the Cuban revolution internationally.
If Cuban government reports are accurate, the numbers are impressive. From 1961 to 2008, 270,743 Cuban “internationalists” worked in 154 countries—124,112 in the health field in 103 countries. 2 By mid-2011, around 40,000 Cuban medical personnel, 16,000 of them doctors, were working for periods of around two years at a time in 68 nations. 3 According to Cuba’s Minister of Health “they were caring for some 70 million people, in some cases the entire population of a country, such as in Haiti.” 4
The Cuban government makes considerable efforts extolling the virtues of the medical brigades. Together with touching stories of the heroic efforts of the “soldiers of the revolution,” precise statistics are widely disseminated in international reports and media coverage of patients seen, consultations completed, deliveries performed, surgeries, etc. Although Cuban doctors report that statistics are systematically tampered with and many reports do not match up,5 there is no doubt that Cuban professionals have cared for large numbers of patients all over the world and particularly those in greatest need. That the missions have “saved millions of lives around the world” may be overstated, but that many lives have been saved and bettered is undeniable.
The Cuban doctors, nurses and health technicians serve under government-to-government agreements. Well over 100 governments—nearly all in Latin America, the Caribbean, Africa and the Arab world—have signed cooperation pacts with Cuba for their sustained presence in their countries. This is no small feat for a small and poor country like Cuba and it usually leads to strengthening ties in other areas.
CUBAN MEDICAL INTERNATIONALISM IN VENEZUELA AND BEYOND
The alliance with Venezuelan President Hugo Chávez has given Cuba’s health diplomacy a tremendous boost. In 2000, soon after Chávez was elected President, Cuba and Venezuela signed a cooperation agreement that established the basis for a growing economic and political alliance. In 2003, the “oil-fordoctors” program was launched, with Venezuela paying Cuba in whole or in part for its health “collaborators” working in Venezuela and other friendly states,6 particularly those within the framework of the Boliviarian Alternative (or Alliance) for the Americas (ALBA). 7 By joining forces to greatly expand medical treatment for traditionally underserved populations, Chávez and Castro found an effective formula to: (1) provide critical aid to Cuba’s ailing economy to keep the Castro regime in power; and (2) boost loyalty and support for their political agenda and revolutionary/ Marxist project.
The presence of Cuban health “collaborators” in Venezuela grew rapidly and massively until 2008 under the aegis of the “Misión Barrio Adentro” (“In the neighborhood mission”), launched in 2003.8 By the end of 2007 there were 29,296 Cuban health professionals in Venezuela—of which 13,020 were doctors. 9 Venezuela also funded a very large vision restoration program, “Misión Milagro” (Operation Miracle), whereby Cuban eye specialists conducted surgeries on marginal populations especially from ALBA countries either by flying the patients to Cuba or by establishing eye clinics in their countries. Millions have been treated.
These services have not been delivered by Cuba for “free,” as Fidel Castro and Cuban officials have publicly and historically insisted.10 In fact, Cuba generally receives payment.11 Examples abound in reports by media and official sources from many host countries. The exception has mostly been for the emergency relief brigades sent as assistance in response to natural disasters, although these often lead to a cooperation agreement involving payment.
Expansion Beyond Venezuela
Cuba’s reported revenues from exports of services declined from $6.2 billion in 2008 to $6.0 billion in 2009, although these statistics may not be accurate (some experts from Cuba have insinuated it includes revenues not actually paid). What seems certain is that these revenues have declined much more since then,12 although Cuba’s official statistics for 2010 are not yet available as of the time of this writing and there have been no public reports on 2011 figures. The figures from official sources indicate that Venezuela’s payments for Cuban professionals include large subsidies. While Venezuelan doctors in the public health system earn the equivalent of US$350 per month,13 Cuba may have been paid around US$16.6 thousand a month for each of its health professionals.14
The expansion of the Venezuela program has represented a massive revenue influx for Cuba, as seen in Table 1. Reductions in expenditures by Venezuela are already reflected in the small decline seen in 2009. The impact of lower oil prices, a world recession and the mounting effects of “Bolivarian” economic management plus uber-spending by Chávez have taken their toll. Already, Venezuela’s “Barrio Adentro” program had seen huge cuts beginning in 2008.15 In 2009 Chávez admitted there was a medical “emergency” after reports that 2,000 of the 6,700 “Barrio Adentro” modules had been abandoned.16 In early 2010, news started to surface of multi-billion dollar loans from China to Venezuela, confirming Venezuela’s economic straits.17
Cuba developed an increasing dependence on the export of professional services for GDP growth; export of professional services surpassed tourism revenues in 2005 and grew to three times tourism revenues by 2008. After the slowdown, “no substitute has been identified in other sectors of the economy, all of which have trailed behind with very low productivity.”18 The decline in hard currency revenue from services exports and the large corresponding deceleration in GDP compounded already serious economic difficulties and triggered a grave internal crisis. As a result, Cuba has doubled efforts to expand its health diplomacy beyond Venezuela.
Table 1. Cuba’s Services Exports (Million Cuban Pesos; Exchange to US dollars 1:1)
An all-out campaign to secure economic survival is at play. Cuba has been increasing the presence of health missions in many different countries. Reports have surfaced of larger or new brigades in the Englishspeaking Caribbean, Africa, the Arab world, and in oil-producing developing countries. Cuba’s efforts in Haiti after the January 2010 earthquake have been particularly noticeable and effective; its medical brigade has grown considerably, with substantial funding from other countries and international organizations. Plans for further expansion with massive international funding are underway.
How is Cuba Fostering the Expansion of its Health Diplomacy?
Training Medical Personnel in Large and Increasing Numbers. Thousands of doctors and other medical personnel are being trained in Cuba. In 2007, 100,000 Cuban doctors, nurses and other medical personnel were being trained for service in the Third World in 23 medical faculties,19 including the biggest medical school in the world.20 By the end of 2010, this number had risen to 147,416, with 50,073 studying medicine, 33,406 nursing, and 52,117 being trained as technicians.21
An international advocate of the Cuban internationalist effort explains: “Cubans, with the help of Venezuela, are currently educating more doctors, about 70,000 in all, than all the medical schools in the United States, which typically have somewhere between 64,000 to 68,000 students enrolled in their programs.”22 Considering the United States has a population 35 times as large as Cuba’s and a vastly larger GDP, this is quite extraordinary. It is probably possible only because the state is the sole employer of medical workers and has strict control over education, dictating what people should or may study. That doctors living in near poverty can earn a bit more abroad and use that to leave the country also helps.
Cutting Health Professionals at Home to Send Them Abroad. In December 2010 Cuba announced a “personnel reduction in the already extremely stretched healthcare sector in order to export more doctors and earn hard currency.” An 11–page document published by Cuba’s Ministry of Health announced a reorganization of the health sector, the closing down of clinics, and the need to turn to natural remedies to reduce costs. It added that the presence of “our paid professionals would be increased in countries whose economies allow it, so they may contribute to the national health system.”23
In June 2011, Cuba’s National Statistical Office reported that in 2010 overall employment in the health sector had fallen 14% from 330,000 in 2009 to around 282,000.24 The cuts corroborate persistent reports of a severe lack of medical personnel since the mid-2000s.
Redoubling Propaganda Efforts Regarding Medical Missions. Cuba’s international public relations efforts to promote medical missions involve compelling multimedia material, extensive internet-based dissemination, and the stewardship and participation of internationally influential figures, including doctors and scholars from leading institutions in the U.S. and Canada. Partnerships and exchanges with top universities, presentations, conferences, and appearances in medical associations all include almost exclusively the views and/or participation of representatives from official Cuba; exiled Cuban doctors who have served in medical missions abroad are never invited so that they could relate their experience free of coercion.25
Cuba has also long focused on bringing influential international figures and health professionals to the island to conferences and to participate in professional “exchanges.” These are carefully designed to create favorable opinions of the Cuban health system and obtain funding and resources abroad while lobbying against the U.S. embargo on Cuba. Lectures, visits, and “exchanges” are staged and tightly managed to expose visitors only to showcase facilities and the officially sanctioned discourse.26
Cuba’s official media portrays the internationalists as “soldiers of the revolution” in the most heroic of terms. There is no doubt that the Cuban health workers do much good in providing care to many of the world’s neediest, regardless of why or how that comes to be. But official reports are loaded with heavy-handed praise and devoid of any mention of aspects that might give pause. Many are relayed verbatim in the local media of host countries—and internationally—and with the help of host government officials. For example, promoting the false idea that Cuba provides the international health services for free is a key aspect of Cuba’s public relations efforts. Many host governments lend themselves to creating this impression by not correcting Cuba’s statements and help portray the Cuban government and the “cooperation” in the best of terms. The partnership with Cuba is very appealing to officials and politicians in many host countries because medical services are delivered at relatively low cost to the state and for free to typically underserved populations in areas where it is difficult or nearly impossible to send local doctors and international volunteers.
Well-designed international dissemination efforts are very effective, especially because they play on humane themes that resonate deeply with most people. Julie Feinsilver, U.S. scholar-author and expert in Cuba healthcare, explains how this brand of medical diplomacy has huge pay-offs for Cuba: it “projects an image of Cuba as righteous, just, and morally superior…” Its health workers “act as goodwill ambassadors that boost support for Cuba and its revolutionary government within important sectors of the host society.” (…) Cuba has “greatly improved both its bilateral relations with those countries as well as its standing and support in a number of multilateral forums,” resulting in “bilateral and multilateral aid as well as trade, credit and investment. Cuba’s success in this endeavor has been recognized by the World Health Organization (WHO) and other UN bodies, as well as by numerous governments, 107 of which have been direct beneficiaries of Cuba’s medical largesse.” 27
Securing More International Assistance to Fund the Health Missions. The Cuban government has doubled efforts in recent years to increase financial assistance from international organizations and developed countries to fund its international medical missions in the developing world. It appears that nowhere has this been more successful than in Haiti.
That some Cuban medical brigades receive funding from governments and international agencies and organizations is rarely even mentioned. Some of this aid is channeled through triangular cooperation with governments of developing countries and/or international NGOs. Examples include aid from Germany for missions in Honduras and Niger, Japan and France also for Honduras, and France, Japan, Norway and Brazil for the mission to Haiti.28 In 2004, South Africa donated US$1million as party to a trilateral agreement to deploy more than one hundred Cuban doctors in Mali and gave another US $1 million in 2010 to support thirty-one Cuban medical professionals in Rwanda for a year.29 WHO, the United Nations Children’s Fund (UNICEF) and the Pan American Health Organization (PAHO) have all funded Cuba’s medical education initiatives and services abroad.30 Cuba could be making considerable profits from some of the missions, given the very low compensation Cuban internationalist personnel receive but, because the agreements are not public, this aspect is unknown.
Using Other Mechanisms of Health Cooperation as Building Blocks to Sending Medical Brigades. Cuba typically moves very quickly to deploy emergency brigades to countries that have suffered a natural disaster. In several cases, this has led to cooperation agreements, a larger and more permanent presence for Cuban medical personnel, and strengthened ties with the host country. Honduras after Hurricane Mitch in 1998, Pakistan after the 2005 earthquake, and Haiti after Hurricane Georges in 1998 and the 2010 earthquake serve as examples. Because Cuba’s government is the sole employer of medical services personnel in the island, it can send specialists at very short notice practically anywhere in the world and have them stay as long as it wishes and under the terms it dictates. The personal concerns of Cuban workers do not figure prominently—if at all—in this equation. This gives Cuba an edge that few can match.
Education is also usually part of a “cooperation” package. Since 1976, Cuba has sent its health professionals to teach abroad and help establish medical schools in other countries.31 Nine countries (including Haiti) have medical schools established with Cuban cooperation.32 Cuba also educates medical students on the island for free to the students, with scholarships from the Cuban state, although it appears that at least some attend with varying contributions from their governments. This has great value for many countries that lack sufficient trained health personnel and do not have teaching facilities. In 2010, Cuba had 15,000 foreign students in medical schools.33 In July 2011, just the Latin American School of Medicine in Havana had graduated 10,000 medical students from sixty countries since 2005, with 1,300 from 48 countries in 2011’s graduating class.34 Cuba projects to train 100,000 doctors for the developing world by 2015.35
CUBA’S HEALTH PROGRAMS IN HAITI
After two major natural disasters—a hurricane in 1998 and a devastating earthquake in 2010—Haiti has provided a perfect opportunity for Cuba to further its interests in a number of ways. Nowhere has Cuba’s strategy to expand its health diplomacy been more obvious and successful than in Haiti.
History of the Cuban Medical Brigade in Haiti
In 1996, Cuban doctors were sent to Haiti to study a serious outbreak of meningitis in the eastern part of the country.36 A disaster relief team was sent after Hurricane Georges struck Haiti in September 1998. Barely a few weeks later, Haitian President René Préval traveled to Cuba and signed a bilateral cooperation agreement; in addition to health, the agreement also covered the areas of education, agriculture, tourism, and sports.37 Two hundred Cuban doctors were deployed together with professionals in other fields; Cuba also agreed to provide specialized training in its hospitals to 100 Haitian medical school graduates. 38 Soon after, Haitian students were studying medicine in Cuba with full scholarships, the first contingent arriving May 1999 at the newly-founded Latin American School of Medicine (ELAM).39
News of extraordinary results of the health services the Cuban medical brigade was delivering in Haiti soon surfaced, although reports were inconsistent. In December 2003, Haiti’s Finance Minister said that “82% of all Haitians had been treated by a Cuban physician or health-care specialist.”40 Cuba’s permanent representative to the United Nations, in turn, reported that Cuban doctors were providing health care for 75% of the Haitian population and had “saved nearly 86,000 Haitian lives in the last five years.”41 Cuba’s Ambassador to Haiti reported in early 2004 that 705 Cuban “internationalists” were in Haiti, of which 579 were in the health sector, “most of them doctors, “who were working in 95% of Haiti’s 133 municipalities.42 By then, 628 Haitian doctors had also been trained by Cuban experts, both at a medical school in Haiti and in Cuba.43 Cuba-Haiti relations prospered. President Préval developed very close ties with Fidel Castro and traveled to Cuba several times, frequently praising Cuban medical assistance to Haiti.
Cuba quickly tapped into international funds to pay for its medical mission in Haiti. In 2003, Cuba’s Ambassador to Haiti praised the “triangular program to fight AIDS with France and other programs with the Pan American Health Organization and UNAID.” But, the assistance was more encompassing. A Cuban doctor who served in Haiti from July 2002 to September 2003 said the full range of comprehensive medical services he provided at a mountain clinic were funded by France.44 In 2006, Cuba received funds from France for a vaccination effort in Haiti plus two million doses of vaccines donated by Japan.45
By 2007, PAHO reported remarkable improvements in Haiti’s health indicators.46 As usual, Cuba put out statistics documenting a gigantic number of health services delivered. Considering that Haiti had a population of around 8.5 million, from December 1998 to May of 2007, the Cuban medical brigade had saved 210,852 lives (in emergencies) and conducted 14.8 million visits (10,682,124 patient visits to doctors and 4,150,631 doctor visits to patients), 160,283 major and minor surgeries, and attendance at 86,633 births.47 Whether the numbers are accurate or not,48 there is no doubt that the presence of Cuba’s health workers was important as well as greatly appreciated by the Haitian population and its government.
By June 2008, however, the number of Cuban health professionals in Haiti had declined to 48849 (from 579 in 2004). By January 2009 more health professionals had left, brining the number down to 344.50 No official explanation for the decline in number of physicians in Haiti has been found, but doctors were being pulled from their assignments overseas and sent to Venezuela,51 where the “Barrio Adentro” program was generating huge flows of revenue for Cuba.
A press release by the Cuban Mission to the United Nations (in New York) put out very detailed data of the medical assistance to Haiti until the time of the earthquake. It claimed that since 1998 some 6,094 Cuban medical personnel had worked there and had reportedly delivered an extraordinary number of medical services—over 14.6 million consultations,52 207,000 surgical operations (including 45,000 vision restoration operations through their Operation Miracle programme53) and 103,000 deliveries/births. However, official Cuban reports conflict, so it is impossible to ascertain actual results in terms of services delivered.54 It was also reported that 917 Haitian professionals were formed in Cuba, 570 as doctors, and 660 others were studying in Cuba (541 in medical school).55 Five Comprehensive Diagnostic Centers “built by Cuba and Venezuela” were serving the Haitian population.56 Countries such as Venezuela, France, Japan and Taiwan, the WHO, PAHO and many NGOs had, by the earthquake, already provided substantial funds for different aspects of the Cuban health mission in Haiti.
CUBA’S EARTHQUAKE RESPONSE
When a devastating earthquake struck Haiti at 9:53PM on January 12, 2010, 403 Cuban collaborators were in Haiti, 344 of them health professionals. They were working in 127 of 137 of the country’s municipalities (communes).57 Within the first 12 hours they treated 605 patients and within 24 hours performed 1,000 emergency surgeries.58 Cuba sent an emergency relief brigade immediately that grew in size over the following weeks. The brigade appears to have been composed mostly of students from ELAM in Cuba, Haitian doctors who had completed their studies there or had been trained by Cubans in Haiti (presumably already in Haiti) and rehabilitation specialists, physical therapists, and epidemiologists from Cuba.
According to an Al Jazeera report from Havana, Cuban doctors immediately organized provision of medical services at three facilities that could be operated after the earthquake, 5 field hospitals, and 5 diagnostic centers, for a total of 22 different care posts. In addition, 400,000 tetanus vaccines were sent from Cuba for treating the wounded, “with financial support from Venezuela and the assistance of 100 specialists from Venezuela, Chile, Spain, Mexico, Colombia, and Canada plus 17 nuns.59 Only ten days after the earthquake, the Cuban contingent had reportedly treated over 20,000 patients and carried out 1,054 surgeries.60
Table 2. Cuban-led Medical Contingent in Haiti, February 1, 2010
Three weeks after the earthquake, Cuba reported 938 collaborators in Haiti, of which 380 were Haitian doctors educated in Cuba.61 Other reports cited Cuban officials indicating that 618 medical personnel had deployed for the disaster and were “working alongside 402 Haitian graduates of Havana’s Latin American School of Medicine.”62 They had reportedly “treated more than 60,000 patients and performed more than 3,500 surgeries.63
Although the numbers of health professionals from Cuba in Haiti pre- and post-earthquake do not coincide in the different reports, the number of medical services they delivered was reported with singular precision. This is quite remarkable considering the special challenges of keeping statistics for disaster response. The figures were, however, mostly dissonant from one report to the other, in some cases greatly so. A table published in the Cuban official press reported the same 938 collaborators having treated 50,000 people and performed 3,400 surgeries 28 days after the earthquake. Another source gave even more detailed breakdowns, but much fewer people treated and surgeries performed.64 Confusing things even more, in a February 23, 2010 speech, Raúl Castro gave even more contradictory figures.65
In April 2010, Cuba’s News Agency reported that the Cuban brigade, consisting of more than 1,100 people—Cubans and graduates and students from Havana’s ELAM—had treated “345,689 patients in the 110 days elapsed since the earthquake.” The services had been delivered “as part of an ALBA accord,” probably meaning funded by Venezuela.66
The U.S. based NGO MEDICC (Medical Education Cooperation with Cuba) put out a document in late July 2010 that emphasized: “While other emergency medical teams have transitioned out of the country, the Cuban-trained doctors from Haiti and 26 other countries continue to serve within the Cuban- led medical contingent, the largest in Haiti.” It reported that the following services had been delivered as of May 2: 341,241 patient consultations, 8,715 surgeries (3,849 major and 4,866 minor), 1,617 attended births, 111,250 persons vaccinated, 72,773 patients receiving rehabilitation services, and 121,405 children and youth receiving psychological services. It is hard to imagine how a contingent of around 1,000 persons (not all doctors) could have accomplished this in four months’ time. However, in thousands of academic and media sources consulted, a face-value reporting of the statistics provided by Cuban officials has been the norm; questioning the reliability or feasibility of data provided by Cuban officials or state-controlled news agencies and institutions is almost entirely lacking.
In October 2010, a cholera epidemic began to ravage Haiti and eventually killed several thousand people. Cuba announced it would send 300 health professionals including transferring doctors posted in other countries.67 In January 2011, the Director General of the Haitian Health Ministry reported that Haiti had 100 cholera treatment centers, including several run exclusively by the Cuban brigade.68 How long they stayed is unclear, but in April 2011, at a Presidential Palace ceremony, Haitian President Préval awarded the National Order of Honor and Merit, the country’s top award, to Dr. Lorenzo Somarriba, chief of the Cuban Medical Mission in Haiti, in recognition of exceptional work in fighting the cholera epidemic. He highlighted the work of the Cuban brigade, which he said had 1,300 members at the height of the epidemic and served in “the most remote areas” of the country.69 News reports failed to mention that Norway had donated to Cuba 5 million Norwegian Crowns (US$850,000) for the cholera response.
In December 2010, the Cuban Communist Party’s official newspaper, Granma, reported that the Cuban Brigade had 1,295 members: 515 doctors, 447 nurses, 244 technicians and 89 support medical personnel. 70 That same month, Cuba’s Vice Minister for Health put the number at 1,334.71 Just days later, on January 12, 2011, the head of the Cuban medical mission to Haiti said, that 720 health professionals were part of the Cuban Mission. He explained that 700 were from ELAM, so that the mission had representatives of 22 countries plus Cuba and Venezuela.72 In July of 2011, a Haitian source reported 410 doctors and 80 other health professionals from Cuba in Haiti.73 It appears that some of the conflicting numbers result from Cuba’s reporting of non-Cuban doctors graduated from Cuban medical schools and medical students as part of the disaster relief contingent, not of the cooperation agreement with Haiti.
In April 2011, Michel Martelly was elected President of Haiti, bringing a less friendly disposition towards Cuban revolutionary ideology. It is too soon to tell if the change in political fortunes in Haiti has had any effect on the Cuban presence in Haiti.
The Strategic Response
Almost before the earth stopped shaking, Cuba was using the Haitian tragedy to increase its legitimacy and global stature, secure more international funds, and push for the relaxation of U.S. sanctions. On January 15, the Cuban Foreign Ministry’s Director of the North America Department issued a statement proclaiming that: “Cuba is ready to cooperate with all the nations on the ground, including the U.S., to help the Haitian people and save more lives.”74 It lauded the deal announced that day by the White House authorizing U.S. flights over Cuba that would cut by 90 minutes the flight time of medical evacuation flights for Haitian earthquake victims from the U.S. Naval Base in Guantanamo to Miami.75 The news was reported in Cuban TV program “Mesa Redonda” (Roundtable), the quintessential voice of the government. Secretary of State Hillary Clinton’s thanks to Cuba was reported as well as her statement that any other action of the government of Cuba in support of Haiti rescue operations was welcome.76
In the U.S., traditional Cuba supporters and antiembargo advocates went to work immediately and in chorus, securing exposure in major media outlets. Forty-two hours after the earthquake, the Director of the American Strategy Program at the New America Foundation was featured by CNN calling for U.S.- Cuba cooperation with Haiti. He argued that the devastation in Haiti provided a platform to move beyond the Cold War stasis in U.S.-Cuba relations and build confidence between Cuban and American authorities. 77 The following day, The Huffington Post published a piece by the Director of the Center for Democracy in the Americas titled “To Increase Help for Haiti, Obama Should Let U.S-Cuba Cooperation Take Flight.”78 Using as stepping stone the agreement on U.S. relief flights over Cuban airspace— announced just hours before—she called for on-the-ground cooperation with Cuba in Haiti, with the Cuban medical brigade serving as a foundation for broad Cuban-U.S. cooperation. The U.S., she said, could help expand the reach and impact of the Cuban medical brigades, offering as examples lending the Cubans durable medical equipment and using U.S. helicopters for transport to inaccessible locations.
On January 18, Cuba’s Permanent Mission to the United Nations in New York issued a press release reiterating “Cuba’s disposition to cooperate with all nations, including the Unites States, in the assistance to Haiti…” It indicated that Cuba had the personnel and infrastructure required to work in Haiti.79 The message had been delivered loud and clear. The U.S. government responded almost immediately, offering medical supplies to Cuba in Haiti. On January 22, a State Department spokesman confirmed the offer had been made (date undisclosed), though Cuba had “not yet formally agreed to accept the aid.”80 On February 5, the U.S. Under Secretary of State for Western Hemisphere cheered the “cooperation” on the flights as an example of “what is possible to overcome differences and concentrate on what is truly important.”81
On March 31, high-ranking diplomats of both countries met to discuss additional cooperation, the highest level of contact in years. The Chief of Staff to U.S. Secretary of State Clinton met with Cuba’s Foreign Minister during a donor conference for Haiti at the U.N. to coordinate medical help for Haiti. Cuba issued a communiqué confirming the meeting that said: “We would hope that future exchanges of this nature are a possibility.”82
The balloon soon fizzled, but with no official explanations on either side. Among possible reasons, the Cuban government had unleashed a wave of internal repression after the February 23 death by hunger strike of political prisoner Orlando Zapata Tamayo.83 The international outcry against Cuba was growing and widespread; for the U.S., the timing may have been ill suited for a rapprochement.
In the earthquake’s aftermath, Cuba’s health collaborators were credited for “providing free and disinterested” 84 services in Haiti amounting to a “contribution” of US$400 million since 1998.85 Lists of lives saved, consultations held, surgeries performed, etc., were continuously updated and made part of most news reports. Media sources disseminating Cuba’s claims have never caught on to the discrepancies in the figures and have almost exclusively echoed Cuban official reports.
International praise and support for Cuba has only heightened. It has been particularly focused, enthusiastic, and loud, from Cuba’s usual fan club. The head of WHO-PAHO in Haiti spoke about their excellent cooperation ties with Cuba and their common efforts, in three non-specified areas of cooperation. 86 The representative of PAHO’s Development Program called on the nations of the world “to follow the footsteps of Cuba and Venezuela in their medical assistance to Haiti.”87 In December 2010, the Secretary General of the U.N., Ban Ki-Moon, addressing a General Assembly session dedicated to the Haitian situation, highlighted the importance of the work of the Cuban medical brigade in the fight against the cholera epidemic. Haiti’s Ambassador to the UN and representatives of several member states chimed in with praise for Cuba.88 Since the Haiti earthquake, many academic events and conferences have been held in different cities and universities in the U.S. specifically on Cuba’s medical brigades, all extolling the virtues of Cuba’s healthcare and international solidarity.89
Not surprisingly, the energized pro-Cuba fete has proved insufficient in appeasing a hearty appetite. Cuba’s official media and many of its advocates began complaining that the international media was ignoring Cuba’s aid to Haiti—that quickly became the subject of many news stories.90
The Business of Humanitarianism
Haiti had been a fertile staging ground for Cuba to enter into trilateral agreements for third parties— international organizations or governments—to provide funding for Cuban medical brigades. Given the large historic levels of international assistance pouring into Haiti, it is not surprising that Cuba had been tapping into it for years. But, the earthquake provided grander opportunities. There are glimpses into Cuba’s seemingly outstanding success in developing this strategy.
Ten days after the earthquake, Norway signed an agreement with Cuba donating 5 million Norwegian Crowns (around US$885,000) for Cuba’s Ministry of Health “to purchase and send medical supplies, resources and inputs for the medical assistance provided by the Cuban medical brigade in Haiti.”91 In late October 2010, it was reported that Norway was “intensifying its cooperation with Cuban doctors in Haiti”92 by donating an additional 5 million Norwegian Crowns. Predictably, in May 2011 there were media reports of Norway-Cuba bilateral agreements in the fields of oil and fishing.93
Thirteen days after the earthquake Hugo Chávez announced that an ALBA delegation would travel to Haiti to propose to President Préval a comprehensive plan for the health sector in the reconstruction of the country.94 It was soon clear from statements by Cuban officials that Cuba intended to take center stage. On February 23, Raúl Castro publicly confirmed that Cuba was “now focusing the mission on advancing Haiti’s long-term health system.”95 Very soon, plans were unveiled for a gigantic and costly endeavor designed to be run by Cubans and Cuban-trained medical staff at a cost of US$170 million per year.
Less than three months after the earthquake, at a U.N. Donors’ Conference for Haiti in New York, Cuba’s Foreign Minister laid out the plan, “The Program for the Reconstruction and Strengthening of the National Health System in Haiti.” He said it had been designed by Haiti with the cooperation of the Cuban government, Venezuela, other countries and humanitarian agencies and that it would be funded with donations from different governments and international organizations. He reported that there were already 783 Cuban doctors working in the program, together with 482 Haitian doctors and 278 specialists from another 28 countries, all graduates of Cuban institutions. Details of the plan offered by the Cuban Minister were:
- 101 primary health care centers were already under construction and the plan was to build 30 community referral hospitals equipped with state-of-the-art technology, 30 rehabilitation wards, and a National Tertiary Health Care Specialties Hospital.
- 80 high level Cuban specialists would work in the hospitals and would be in charge of clinical departments and services, research, teaching and training of the Haitian professionals who would progressively replace the Cuban professors.
- The project would cost approximately US$170 million dollars per year (US$690.5 million for the first four years), a cost that included the medical services offered by Cuba, estimated at half the international prices. Contributions would also fund the training of another 312 Haitian doctors in Cuba.96
Venezuela pledged the initial impetus and funds for the program. On January 25, Chávez announced the creation of an ALBA humanitarian fund of US$100 million for Haiti and said they would be proposing a comprehensive health plan.97 At the March 2010 U.N. Donor Conference on Haiti, Venezuela announced that its 5–year assistance to Haiti (2010– 2016) would total US$2.4 billion. A year after the earthquake, however, Venezuela had relatively low assistance flows to report (given the large sums pledged), but it had reportedly delivered US$20 million “to a Cuban project to build 10 integral medical centers and distribute needed medicines to the Haitian people.”98 Cuba’s Health Vice Minister reported that Cuba had created more than 24 campaign hospitals and 30 rehabilitation centers with the support of nations from ALBA, especially from Venezuela.99 At the end of December 2010, Cuba’s Vice Minister of Foreign Trade and Investment said that “the solidarity of other governments with Haiti is channeled through the Cuban medical mission.”100
Brazil is an important donor country. When the Cuban Foreign Minister spoke of the new health plan for Haiti at the U.N. on March 31, 2010, a Memorandum of Understanding had already been signed on an “important” and “decisive” contribution made by President Lula and Brazil. Brazil’s Minister of Health, José Gomés, later reported that Brazil had signed an agreement committing Cuba, Brazil, and Haiti to unite forces to reconstruct the health system in Haiti.101 Brazil was providing US$70 million in funding for 10 urgent care units, 50 mobile units for emergency care, a laboratory and a hospital, among other health services.102
NGOs from different countries have also made considerable donations. Because there is no international clearinghouse for these funds, it is impossible to figure out how much money Cuba has raised in support of its brigade in Haiti. The California-based non profit MEDICC has two support programs for the Cuban medical mission in Haiti. After the earthquake, it raised over $250,000 from foundations, companies, and individual donors to support Cuba’s relief efforts.103 It has also teamed up with the Pittsburgh- based Global Links to ship material aid to health centers and hospitals where the Cuba brigade is working.104 Global Links has also, among other things, shipped nearly $50,000 of antibiotics and other medical supplies donated by the University of Pittsburgh Medical Center to the Cuban mission. By Fall 2010, the Canadian Network for Cuba had raised and sent $143,231.63 to an account established in Havana “to help fund the outstanding work” in Haiti of the Cuban-led medical team.”105 The nearly half a million dollars from just three NGOs may be just the tip of the iceberg.
The Cuba-Haiti Cooperation Agreement
A source with close ties to the newly-installed Martelly government reports that “the agreements under Aristide and Préval were secret” and that the ones under Préval were thought to have been between him and Fidel Castro directly.106 Efforts to obtain a copy of the agreement on the health cooperation were unsuccessful, reportedly because the office of the President and the Ministry of Health could not find it. A trilateral Haiti-Venezuela-Cuba agreement is funded by PetroCaribe,107 but “other governments and international agencies provide funds for the Cuban medical mission that the Haitian government is not informed of.” What the Haitian government does know regarding the Cuban medical brigade is that the Cuban professionals presently receive US$300 plus lodging and transportation, paid by Haiti. Regarding the credentials of the health professionals, they have not been verified. The government understands that “the Cuban doctors are welcome by the population, especially because they serve in very poor and rural areas.”108
If reports are accurate, a large number of those serving in the Cuban brigade are medical students or recent graduates. Haiti may have become an ideal practice location for ELAM’s students, especially because complaints are being heard from the Cuban population of inadequate care from foreign medical students and recent graduates forced upon them.109 Given concerns raised in different countries regarding the adequacy of training and the credentials of Cuban doctors, the question of qualifications would presumably be of interest to Haitian authorities charged with safeguarding even those desperately poor.
No statistics or reports are available of what the actual cost of the Haiti missions might be for Cuba. It is impossible to determine how much Cuba might be deriving in net financial gain from the cooperation agreement with Haiti or if the additional relief contingent Cuba sent to resulted in net gains or losses. In 2006 the Cuban Ambassador to Haiti reported that Cuba was spending $520,000 a year for transporting its experts to Haiti, as “the Cubans themselves don’t receive salaries.”110 Given that this is contrary to what is known about the brigades, it is unclear what he was concealing or how Cuba was accounting for the donations received in trilateral arrangements. Transport between Cuba and Haiti is probably not very significant given the proximity of both islands to each other.
Whether or not the Cuban “contribution” was accurately reported by the Ambassador, Cuba gets a lot of bang for its buck in terms of international legitimacy, support, and influence from its medical brigades. There is probably no better aid than what can be seen, touched, and felt, such as the care provided by doctors and nurses—especially so when a strong communications plan to exert maximum influence. As a point of comparison, since 1998, the U.S. has spent billions in direct government aid to Haiti, yet very little credit has been derived from it.
Conditions of Service for the Cuban Health Professionals
Cuba’s brand of health diplomacy could hardly be possible if Cuba were not a totalitarian state, guaranteeing a steady pool of health professionals as temporary “exportable commodities.” Because the entire health sector is in state hands and no health workers are allowed to practice privately, they must work for the state for compensation at a monthly average of around US$22–25, which barely provides enough for survival. Moreover, the health workers are captive; Cuba is one of very few countries in the world that forbids its people to leave the country without government permission and punishes doing so with jail.111 Health professionals face the strictest restrictions. They may not travel abroad without a ministerial authorization, which is nearly impossible to obtain. 112
It is not surprising, then, that many Cuban healthcare personnel welcome the opportunity to be part of foreign missions for material gain: the possibility of buying computers and electronics they cannot get in Cuba, to obtain the hard currency bonus for those who serve two years, to gather some savings, and to bring back to Cuba consumer goods at the end of the mission.113 Some see a foreign assignment as their only chance to leave the country.
Cubans sent abroad, including to Haiti, must leave their families behind and face the same systematic lack of labor rights affecting all workers at home. They usually face an extraordinarily heavy workload and lack privacy and recreational activities. Allowed limited contact with family left at home (in Venezuela only two monthly phone calls to Cuba no longer than ten minutes are permitted), they are forbidden from speaking to the media and face many arbitrary restrictions—including not being allowed to drive a car, spend the night out of the assigned lodging, maintain working or personal relationships outside of the scope and place of work, marry foreign residents, accept gifts, travel to other parts of the country. 114 The long list of what is “strictly forbidden” includes “expressing opinions against the government, the political regime, the health care system or any institutions of the country” and having any relation with persons opposed to the Cuban revolutionary process or who have defected from the brigade or left Cuba.”115
The compensation of Cuban health professionals serving in Haiti—at least those who are under the framework of the cooperation agreement—appears to be in line with what Cuban health professionals receive when working in other countries: (1) a stipend in local currency to cover food and basic necessities (currently $300 per month in Haiti) 116; (2) their usual monthly salaries in Cuban pesos (around US$22–25) paid to their families in Cuba plus US$50 per month the first two years and US$100 monthly if they stay longer; and (3) a bonus accruing US$50 the first six months of service, US$125 from month 6 to month 24, and US$325 thereafter that may only be accessed if they successfully complete their assignment and return to Cuba immediately afterwards. 117
Haiti also pays for the lodging, which is often quite precarious. Health professionals—in Haiti and elsewhere—must often go to far-flung and inaccessible areas with poor conditions. 118 In Venezuela, for example, they must serve where local doctors refuse to go due to insecurity. 119 A doctor who served in Haiti reported having lived alone in a small clinic in a remote mountain area that had no running water. He was completely cut off from civilization, did not speak Creole and had no interpreters. After arriving, he had been unable to call his family (wife and child) in Cuba for five months.120
It has been reported at least for some countries that the internationalists must pay designated quotas to Cuban Communist Party organizations and attend frequent political meetings run by their supervisors and handlers. It is uncertain if this still applies in Haiti, but presumably it does, at least for the Cubans who are part of the permanent brigade. Like in other countries, the Cuban mission to Haiti is highly structured for administrative and political purposes. In 2003 there was, reportedly, a central administrative command and nine departments organized by geographical area, each charged with the respective municipalities and towns, and then with smaller brigades and eventually with individual clinics. Parallel to this structure is the political command, with the Department of State Security and the Communist Party operating at the same levels as the administrative structure. The internationalist medical professionals are, according to the cited Cuban doctor who served in Haiti, “indoctrinated, compromised and prepared to inform, turned into (political) collaborators. … The strategy is not to know who to suspect as being an informant, that’s why it’s so effective.”121
Under surveillance and required to inform on coworkers, some health professionals sent abroad have been trained by Cuba’s intelligence services to monitor the host country, diffuse opposition to the socialist model, and spread propaganda. The new (Martelly) government knows that the Cuban collaborators play a double game in “collecting intelligence. The Préval government “didn’t care,” but the current government is trying to figure out how to deal with this.”122
If Cuban health workers defect,123 they are considered “traitors,” their families are not allowed to leave to join them,124 and they may not obtain documents on their education and career track (it is punishable by law for any government worker in Cuba to deliver them).
During the Préval government, Cuban doctors who defected did not stay in Haiti for fear of being captured by Cuban security agents operating there. Most would go to the Dominican Republic instead.125
IMPLICATIONS AND CONCERNS126
Implications and concerns about Cuban medical internationalism pertaining to Haiti include:
- Questionable quality of healthcare and lack of accountability with repercussions for patients in host countries. The massive and accelerated training of health professionals for “export” raises concerns regarding quality. This has led medical associations in host countries to question their experience and credentials.127 Some “doctors” are sent abroad without completing the last two years of medical training. Malpractice allegations have surfaced in several countries, including Haiti, with little recourse for patients. Some countries—such as Panama, Honduras and Brazil- have terminated their cooperation agreements with Cuba and sent the Cuban internationalists back.
- Selective humanitarianism: helping others, but forgetting Cubans. Many cooperation agreements include the provision by Cuba of medicines and medical supplies, while the Cuban population faces their chronic absence and systemic equipment lacks and failures. Rampant misery, corruption, and wretched healthcare facilities are standard fare in Cuba.128 To make a dire situation worse, there is a severe shortage within the island of doctors, especially specialists, nurses and technicians. Because Cuba is a dictatorship, the anger and frustration of its citizens can find no outlet in the national media or corrected through civil society or political action.129
- Excessive external economic dependence by Cuba. Seventy-five percent of Cuba’s exports of services relate to exports of services by Cuban professionals, with limited multiplier effects in the economy. The large hard currency revenues derived from these services greatly diminish pressure to make badly needed structural economic reforms, including a dedication of resources to more stable and development-inducing productive activities. It has also made the Cuban economy extremely dependent on an external factor that could quickly disappear, for example if there were regime change in Cuba or Venezuela.
- Violation of domestic laws and international human rights standards affecting the Cuban health professionals. The cooperation agreements are believed to violate the domestic legislation of most host countries as well as international agreements, including the Trafficking in Persons Protocol, 130 several ILO (International Labor Organization) Conventions, such as the Convention on the Protection of Wages of 1949 and Convention No. 29 of 1930 concerning forced or compulsory labor. They also trample on important international standards concerning the prohibition of “servitude”131 and “slavery.”132
1. Rafael del Pino, Proa a la libertad (Mexico: Editorial Planeta, 1991), p. 250. (del Pino was Brigadier General and Second in Command of Cuba’s Air Force. He defected and escaped Cuba with his family in May 1987.)
2. “Cuba to extend medical collaboration to 81 countries,” Granma International, April 1, 2008. From 1961 to mid-2011, 130,000 were reported to have worked in 102 countries. (Katelynn Northam, “The influence of Cuban medical internationalism— ‘Cooperation—not aid,’” Dalhouise University, July 15, 2011. http://www.dal.ca/news/2011/07/15/the-influence-of-cuban-medicalinternationalism. html).
3. Cuba’s Deputy Minister of Public Health, Marcia Cobas, cited in: “Cuban Cooperants Awarded Internationalist Medal,” Radio Cadena Agramonte, 25 June 2011. (The number seems to have declined, both in doctors serving as well as countries served, as in November 2008 it was reported that 38,544 Cuban health professionals were serving in 75 countries, 17,697 of them doctors—the vast majority (29,296) in Venezuela. See Steve Brouwer, “The Cuban Revolutionary Doctor: The Ultimate Weapon of Solidarity, “Monthly Review, January 2009. (Brouwer cites the official newspaper of the Cuban Communist Party, Granma, November 3, 2008.)
4. Luis Hernández Serrano, “Médicos cubanos atienden a 70 millones de personas en el mundo,” 13 de abril de 2008, digital@jrebelde. cip.cu (in the page of the Cuban Ministry for Foreign Relations, Cuban Embassy in Egypt. http://emba.cubaminrex.cu/Default. aspx?tabid=16739).
5. The author has extensive first-hand testimony from health professionals who have served in Cuba and abroad of the systematic and consistent manipulation of statistics by the Cuban government. One such report is from a doctor who served in Cuba as well as in missions in Haiti and Venezuela and who simply declared: “Cuba’s statistics are false. We are told what we need to report.” (Dr. Joel de la Torre, interviewed in Miami, February 1, 2011.)
6. The payment scheme is unclear and is not reported by Cuba or Venezuela. It is said to involve the sale of oil to Cuba at subsidized rates and with very loose credit terms, with Cuba reselling such oil in the open market. (See M.Werlau, “Cuba-Venezuela Health Diplomacy: The Politics of Humanitarianism,” Cuba in Transition—Volume 20, Washington: Association for the Study of the Cuban Economy, 2010, footnote 18.)
7. Cuban officials and the Cuban media consistently report on the medical programs and international missions within the context of the ALBA. ALBA seeks the political, economic, and social integration of the Caribbean and Latin American countries in “an alternative model to neoliberalism,” essentially meaning Marxism-Leninism. ALBA countries are: Antigua and Barbuda, Dominica, Bolivia, Cuba, Ecuador, Honduras, Nicaragua, St. Vicente & Grenadines and Venezuela.
8. The “Misión Barrio Adentro” arose as part of the Integral Agreement of Cooperation between Cuba and Venezuela and began to operate formally on May 22, 2003, with the participation of 200 Cuban and 30 Venezuelan doctors and an initial investment of one billion Bolívares. Bolivarian Republic of Venezuela: Health Situation Analysis and Trends Summary, PAHO—Pan American Health Organization. http://www.paho.org/english/dd/ais/cp_862.htm. 9. 13,020 doctors, 2,938 odontologists, 4,170 nurses and 9,168 “health technicians” were serving in Venezuela. (“MinSalud desmiente a Provea: 30 mil médicos, odontólogos y técnicos cubanos están en Venezuela,” 10 diciembre 2008. http://www.radiomundial.com.ve/ yvke/noticia.php?t=16023).
10. According to Fidel Castro, by 2003, 52,000 doctors and health professionals had served “voluntarily and for free” in 93 countries. (“Los pueblos dirán la última palabra,” Versiones Taquigráficas, Consejo de Estado, “Cuba demanda sustitución de organismos financieros internacionales,” Prensa Latina, La Habana, 5 febrero 2003. Discurso pronunciado por el Comandante en Jefe Fidel Castro Ruz, Santiago de Cuba, 26 de julio del 2003. http://www.jrebelde.cubaweb.cu /2003/julio_septiembre/jul-27/lospueblos.html).
11. For example, in 2000, Cuba was receiving monthly revenues estimated at US$1.2 million from Zimbabwe and in 2007, South Africa was paying the Cuban government US$3,800 to $4,400 per month for each doctor. See Werlau, op.cit.
12. The author confirmed this with an economist from Cuba during his visits to New York City in 2010 and 2011.
13. Mary Anastasia O’Grady, “Venezuela’s Docs Flee—So Does Chávez,” The Wall Street Journal, July 18, 2011.
14. Calculation based on official 2008 and 2009 statistics from Cuba on the number of health professionals serving abroad and the amount of services exports.
15. PDVSA, the state-owned Venezuelan oil company, reported spending US$1.7 billion in 2006 and $3.3 billion in 2007 in the Barrio Adentro program, but only $130 million in 2008 and a mere $7 million in 2009. In 2010, there was a reported increase to $650 million, however, this was far below the 2006 and 2007 levels, when Cuba was reporting a bonanza in export services. It is unclear how much this number reflects payments to Cuba, but no doubt the declining investment of resources in the program is evident. (Aportes realizados por PDVSA al Desarrollo Social, Desarrollo Social PDVESA, 2010, http://www.pdvsa.com/interface.sp/database/fichero/free/ 6770/1399.PDF).
16. Louise Egan, “Chavez’s socialist medicine dream may be liability,” Caracas, Reuters, August 18, 2011.
17. Simon Romero, “Chávez Says China to Lend Venezuela $20 Billion,” The New York Times, April 18, 2010; Ian James, “Hugo Chavez: China granting Venezuela $4B loan,” Associated Press, July 9, 2011.
18. Omar Everleny Pérez & Pavel Vidal Alejandro, “Cuba’s Economy: A Current Evaluation and Several Necessary Proposals,” in Jill Hamberg, et.al., Editors, Perspectives on Cuban Socialism, Socialism and Democracy, No. 52, March 2010, p. 74. (Both economists work in Cuba in state-run academic institutions.)
19. Pablo Bachelet, “U.S. program for defecting Cuban doctors a success,” The Miami Herald, March 11, 2007.
20. Northam, op.cit.
21. “Medicina: Cambios en el sistema de Salud de la Isla,” CubaEncuentro.com, 4 Diciembre 2010.
22. Brouwer, op.cit.
23. “Medicina: Cambios en el sistema de Salud de la Isla,”op.cit. Brouwer, op.cit.
24. There was a 34% drop in technical and auxiliary workers, down from 134,000 the year before to 88,000. The number of doctors had risen slightly, from 74,880 to 76,506, while the ranks of nurses thinned from 106,436 in 2009 to 103.014 in 2010. (Mauricio Vicent, “El Gobierno de Raúl Castro reduce en un 14% el área sanitaria,” La Habana, El País, 13 junio 2011; “Cuba announces work force reduction in health care,” Havana, Associated Press, June 1, 2011.)
25. Two examples of the far-reaching public relations efforts directed at promoting the medical missions include: (1) The non-profit organization MEDICC – Medical Education Cooperation with Cuba, which seeks to inform others of “Cuba’s singular and evolving health practices, research and policies” and to promote “the Cuban experience to inform global debate, practice, policies and cooperation in health” (www.medicc.org); and (2) The 2008 documentary film “Salud,” produced by an Academy Award nominee, on “Cuba’s example and its cooperation programs” that has been widely disseminated to target audiences with strong support from influential international figures in the field of health. (See website for the film at http://www.saludthefilm.net.)
26. The author has gathered extensive first-hand testimony of this from Cuban health professionals and also experienced an official visit to a Havana hospital during a trip to Cuba in 1998. The most recent testimony is from Rodolfo Stusser, M.D., who left Cuba in 2010. In Cuba he had been involved from 2000 to 2002 with the U.S. exchange program People-to-People Ambassador Program (www.peopletopeople.com), receiving at least 700 U.S. visitors from the health field. Dr. Stusser states he was removed from the program and ostracized for attempting to add some “balance” to the persistent window-dressing that Cuban officials demanded for the visitors that created an all-around artificial atmosphere. He reports that visitors were systematically duped, taken only to designated health facilities not reflective of the reality of the rest of the public health system in Cuba. Cuban health workers, he says, must go along or lose their livelihood and face reprisals. (Extensive personal and telephone interviews, June to October 2011.)
27. Julie Feinsilver,”Fifty Years of Cuba’s Medical Diplomacy: From Idealism to Pragmatism,” Cuban Studies (2010).
28. Honduras offers a good example. Germany, France and Japan, working through PAHO, paid $400 per month for each Cuban doctor plus medicines for the Cuban brigade sent to Honduras after a hurricane in 2005. (Joel Millman, “New Prize in Cold War: Cuban Doctors,” The Wall Street Journal, January 15, 2011; Freddy Cuevas, “Maduro: médicos cubanos se quedarán otro año en Honduras,” Associated Press, Tegucigalpa, 31 Agosto 2005.) Japan donated US$57 million to equip a hospital in Honduras staffed by Cubans specialists. (Julie Feinsilver, “Cuban Medical Diplomacy: When the Left Has Got It Right,” COHA-Council on Hemispheric Affairs, October 30, 2006.)
29. Fiensilver, “Fifty Years of Cuban Medical Diplomacy,” op.cit.
30. Feinsilver, “Cuban Medical Diplomacy,” op.cit.
31. On February 2010, Cuba’s Vice Minister of Higher Education, Rodolfo Alarcón, reported that 30,480 foreigners from 129 countries had graduated from Cuban institutions. (“Reconocen importancia de fortalecer vínculo entre conocimiento y desarrollo,” Juventud Rebelde, 10 February 2010.)
32. John Kirk and H. Michael Erisman, Cuban Medical Internationalism: Origins, Evolution, and Goals, New York: Palgrave MacMillian, 2009, p. 5. (The nine countries are Yemen, Guyana, Ethiopia, Uganda, Ghana, The Gambia, Equatorial Guinea, Haiti, and Guinea Bissau.)
33. “Medicina: Cambios en el sistema,” op.cit. (citing data published by Cuba’s Health Ministry).
34. “Escuela Latinoamericana de Cuba graduó 10.000 médicos de 60 países desde 2005,” La Habana, EFE, 28 July 2011.
35. Conner Gorry, MEDICC Review, Summer 2008, Vol 10, No 3.
36. “Cuban Doctors to Haiti,” Caribbean Update, May 1, 1996.
37. Most countries in Latin America and the Caribbean had cut diplomatic relations with Cuba in the early 1960s in reaction to Cuba’s hemispheric subversion and internal human rights violations. In 1962 Haiti had cast the decisive vote excluding Cuba from the Organization of American States. Diplomatic ties between Cuba and Haiti had been re-established in February 1996, as the last official act of former President Jean-Bertrand Aristide. This was considered a snub to the United States (in 1994 the U.S. had sent 20,000 troops to Haiti to oust a military dictatorship and restore Aristide to power after a coup). With the normalization of relations, a process of growing friendship began. 38. Michael Norton, “Cuba sending doctors to Haiti in first Cuban-Haitian accord in 36 years,” Port Au Prince, Haiti, Associated Press, November 13, 1998.
39. Emily J. Kirk and John M. Kirk, “One of the World’s Best Kept Secrets: Cuban Medical Aid to Haiti,” Center for Research on Globalization, Global Research, April 11, 2010. (For details on ELAM, see the school’s website at http://www.sld.cu/sitios/elam/ and Medicc.org.)
40. Larry Luxner, “Cuba sends 705 doctors, teachers to impoverished Haiti,” CubaNews, December 1, 2003.
41. Citing Cuban representative to the U.N. Orlando Requeijo, at a U.N. press conference in New York (W. Steif, “Cuban Doctors Aid Strife-Torn Haiti,” The State, April 26, 2004. op.cit.).
42. Steif, op.cit.
43. Luxner, op.cit.
44. Dr. Joel de la Torre, interviewed in Miami, February 1, 2011.
45. Feinsilver, “Cuban Medical Diplomacy,” op.cit.
46. Great improvements were reported in infant, child and maternal mortality as well as in life expectancy. (Kirk & Kirk, op.cit.)
47. Kirk & Kirk, op.cit.
48. Haitian President René Préval had provided very dissimilar statistics just a year earlier, which means that a lot of catching up would have had to be done to arrive at the 2007 figures. Préval had indicated in April 2006 that Cuban doctors had been involved in more than eight million consultations and had performed over 100,000 operations in Haiti. (“VOA News: Haiti’s Préval Welcomes Cuban Medical Help,” US Fed News Service, Including US State News, April 14, 2006.)
49. Gorry, op.cit. Table 1: Cuban Health Professionals Serving Abroad, June 2008.
50. “Fact Sheet: Cuban Medical Cooperation with Haiti, Medical Cooperation with Cuba,” January 15, 2009 http://www.medicc.org/ ns/index.php?s=104>.
51. This was related to the author by a Cuban doctor who served 14 months in Haiti of a 2–year assignment and was sent to Venezuela, from where he later defected. (Dr. Joel de la Torre, op.cit.)
52. Curiously, this number is lower than the 14.8 million consultations reported above through to May 2007.
53. The Operation Miracle program has been reportedly fully funded by Venezuela. See Werlau, op.cit.
54. For example, a December 2010 report by Cuba’s News Agency cites Cuban Health Vice Minister Marcia Cobas affirming that “more than 3,500 health cooperants” had “performed 16 million consultations.” In other words, half the personnel performed around 1.5 million more consultations. A statement delivered by Cuba’s Foreign Minister at a United Nations’ Donor’s Conference for Haiti in New York offered different figures: “In the course of the previous 11 years of work, the Cuban medical brigade had been present in 127 of the 137 Haitian communities, it had saved 233,442 lives, offered more than 14 million consultations, performed 225,000 surgeries, assisted 109,000 child deliveries and recovered or improved the sight of 46,000 Haitians through Operation Miracle.” (“Statement by Mr. Bruno Rodríguez Parrilla, Minister for Foreign Affairs of the Republic of Cuba at the Haiti Donors Conference, New York, March 31, 2010.” http://www.cubaminrex.cu.)
55. “Llama Cuba en la ONU a la cooperación internacional por Haití,” Cuba Debate, 18 de enero de 2010, www.cubadebate.cu.
56. Ibid. (MEDICC reported slightly different numbers: 550 medical students had graduated in Cuba, 400 of which were back at work in Haiti with Cuban doctors in public hospitals and clinics across the country, and 567 students were enrolled at medical school in Cuba. See Fact Sheet: Cuban Medical Cooperation with Haiti, op.cit.)
57. Updates, MEDICC, op.cit. using as sources Agencia Cubana de Noticias, Granma, Juventud Rebelde.
58. John Burnett, “Cuban Doctors Unsung Heroes of Haitian Earthquake, ”National Public Radio report, January 24, 2010.
59. Tom Fawthrop,“Cuba’s aid ignored by the media?,” Havana, Al Jazeera, 16 February 2010.
60. Vito Echevarría, “Cuban medics offer a lifeline to Haitian quake victims,” CubaNews, February 1, 2010.
61. Hugo García, “El médico ‘español’ de la CNN” Juventud Rebelde, 10 de Febrero de 2010. The contingent of 938 was reported as composed by 280 young Haitian doctors, at least 60 more were Haitian medical students enrolled at the Latin American Medical School in Cuba, 70 were physical therapists and rehab specialists from Cuba, and 64 were epidemiologists and nurses from Cuba working with the Haitian medical students in some 40 makeshift settlements around Port-au-Prince. (Fawthrop, op.cit.)
62. Nick Miroff, “Cuban Doctors in Haiti,” Boise Weekly, February 17, 2010.
64. Juventud Rebelde, newspaper of the Cuban Communist Youth, reported 34,500 patients seen and 2,728 surgeries, of which 1,297 were highly complex surgeries, plus 380 amputations of upper limbs, 644 of lower limbs. (García, op.cit.)
65. “Cuban docs expand Haiti coverage,” CubaNews, March 1, 2010. (Raúl Castro, speaking to Latin American and Caribbean leaders in Playa del Carmen, Mexico, said that Cuba’s medical mission in Haiti had grown to nearly 1,440. The Cuban brigade was reported to include nearly 800 Cuban doctors and other health-care workers, as well as 637 doctors from Haiti and 26 other countries who trained at Havana’s ELAM. To date, the Cuban mission was said to have treated over 95,000 Haitians and performed 4,500 surgeries.)
66. According to figures provided by the Cuban Medical Coordinating Group in Haiti, over 8,000 surgeries, 1,629 deliveries, 73,510 vaccinations for tetanus and other diseases, and 74,657 patients had received rehabilitation services. In coordination with Haitian authorities’ program for the mitigation of the psychological and social damage caused by the earthquake, Cuban staff had contributed with 547 mental health actions including recreational activities, games and sports, among others, in which over 121,000 children and youngsters have participated.” (“Cuba: Some 345,000 Haitians Treated by the Cuban Medical Brigade,” IPR Strategic Business Information Database, May 9, 2010. Source: Cuban News Agency.)
67. Fifty-six were reported to have arrived in a third such group, including 14 doctors who were serving in Bolivia, Mexico, Peru, Ecuador, Paraguay and Colombia (“Cuba envía a Haití más médicos para combatir el cólera,” CubaEncuentro.com, 14 dic. 2010.)
68. Frances Robles, “Cuban doctors are on the rural frontlines in Haiti’s cholera epidemic,” The Miami Herald, March 3, 2011.
69. “Presidente haitiano condecora a la Brigada Médica cubana,”Juventud Rebelde, 21 de Abril del 2011.
70. Juan Diego Nusa Peñalver, “New Henry Reeve Brigade arrives in Haiti,” Granma International, December 23, 2010.
71. “Cuban Doctors Save 250000 people in Haiti,” Havana, Cuban News Agency, December 29, 2010.
72. “Médicos cubanos continúan fortaleciendo sistema de salud de Haití a un año del sismo,” Telesur, 12 enero 2011. 73. Stanley Lucas (Chairman, Haitian Coalition and Co-Chair, Greater Washington Haiti Relief Commission), by telephone, July 22, 2011.
74. “Cuba dispuesta a trabajar con Estados Unidos en apoyo a la devastada Haití,” Mesa Redonda, 15 enero 2010 (mesaredonda.cubadebate. cu).
75. David Jackson, “Obama government deals with Cuba over Haiti relief,” USA Today, January 15, 2010.
76. Translated from Spanish. (“Cuba dispuesta a trabajar…, Mesa Redonda, op.cit.)
77. Steve Clemons, “U.S. and Cuba should work together to help Haiti,” Special to CNN, January 14, 2010 4:17 p.m. EST.
78. Sarah Stephens, The Huffington Post, January 15, 2010 03:55 PM.
79. Llama Cuba en la ONU…, op.cit.
80. Juan Tamayo, “U.S. offers Cuba medical supplies for Haiti,” The Miami Herald, January 25, 2010.
81. Translated from Spanish. (“EEUU se congratula por colaboración con Cuba en ayuda a Haití,” Agence France Press, 5 de febrero 2010.)
82. Paul Haven, “Top Cuban, U.S. officials meet,” Associated Press, April 2, 2010.
83. News coverage was extensive. See, for example: “Cuban prison hunger striker dies,” BBC News, February 24, 2010.
84. “Llama Cuba en la ONU,” op.cit.
85. Cuba’s Foreign Minister stated that medical services provided by Cuba in Haiti were “valued at” US $400 million. (“Statement made by Mr. Bruno Rodríguez Parrilla,” op.cit.) However, other sources report it as money spent and donated by Cuba in its mission to Haiti. (See, for example, “Cuba for Haiti Fundraising Campaign,” The Newsletter of the Canadian Network on Cuba, Issue 3, Fall 2010, www.canadiannetworkoncuba.ca).
86. “Health Organizations Praises Cuban Doctors’ Assistance to Haiti,” Cuban News Agency, May 28, 2010.
87. “PAHO Calls Nations to Follow Cuba’s Example,” Cuban News Agency, May 31, 2010.
88. “Cuban Medical Aid to Haiti Highlighted at the UN,”IPR Strategic Business Information Database, December 6, 2010.
89. One example: In April 2010, MEDICC co-sponsored with the Center for International Policy an international conference in Washington, DC on “Cuban Public Health Cooperation in Haiti” with the goal to help educate policymakers and the public on multilateral reconstruction efforts. (See Elizabeth Newhouse and Wayne Smith, Conference Report, May 2010, Conference: Cuban Public Health Cooperation in Haiti, University of California’s Washington Center, Washington D.C., April 21, 2010.)
90. Examples abound in the media and in academic circles. See, for example, “Cuba: Decries Silence of European Media on Help to Haiti,” IPR Strategic Business Information Database, December 6, 2010.
91. Translated from “Acuerdo de Cooperación Humanitaria entre Cuba y Noruega e Implementación del Donativo Noruego Como Ayuda de Emergencia a Haiti,” text of the agreement provided to the author by the Norwegian government, via email, September 20, 2011.
92. “Norway gives NOK 5 million for medicines and equipment in Haiti,” M2 Presswire, October 29, 2010.
93. “Cuba y Noruega firman acuerdos en los sectores del petróleo y la pesca,” La Habana, EFE, 17 mayo 2011.
94. “ALBA aprueba proyecto integral de ayuda a Haití,” 25 enero 2010, www.escambray.cu.
95. “Cuban docs expand Haiti coverage,” CubaNews, March 1, 2010.
96. “Statement by Mr. Bruno Rodríguez Parrilla,” op.cit.
97. “ALBA aprueba proyecto integral de ayuda a Haití,” op.cit.
98. “A Year After Haiti Earthquake, Venezuela Remains Committed to Reconstruction,” Press Office, Embassy of the Bolivarian Republic of Venezuela in the U.S., January 13, 2011. (Venezuela forgave Haiti’s US$395 million debt to PetroCaribe, an energy cooperation agreement between the two countries immediately after the earthquake and subsequently sent large shipments of aid to Haiti and built a tent city, donated oil at first and then sold it to Haiti at preferential prices and delivered other smaller assistance projects.)
99. “Cuban Doctors Save 250,000 People in Haiti,” op.cit.
101. Venezuelanalysis.com, July 21, 2011, citing Steve Brouwer, Revolutionary Doctors: How Venezuela and Cuba Are Changing the World’s Conception of Health Care, New York: Monthly Review Press, 2011.
102. Fawthrop, op.cit.
103. Echevarría, op.cit.
104. See http://www.medicc.org/ns/index.php?s=4&p=4.
105. “Cuba for Haiti Fundraising Campaign,” The Newsletter of the Canadian Network on Cuba, Issue 3 – Fall 2010 (www.canadiannetworkoncuba. ca).
106. Lucas interview, 7/22/2011.
107. Oil alliance of Venezuela with nations of the Caribbean for the sale of Venezuelan oil at preferential terms. Haiti is a member.
108. The doctor interviewed for this study, who spent 14 months in a remote area of Haiti, said he grew extremely fond of the Haitian people and cared very much about them. He had excellent relations with the Haitians he interacted with and was very moved by the experience. (Dr. J. de la Torre, op.cit.)
109. An independent news report from the island states: “The majority of Cubans do not accept the imposition of newly graduated foreign doctors at the emergency wards. What’s more, they will not resign themselves to serve as guinea pigs.” (Translated from Spanish from: Augusto César San Martin, “Demasiados médicos extranjeros,” La Habana, Primavera Digital, 28 de Junio de 2011. www.primaveradigital. com).
110. Luxner, op.cit.
111. Article 216 of Cuba’s Penal Code (Ley No. 62 of 29/12/1987) forbids citizens from leaving the country without government permission and punishes attempts to do so with one to three years of prison.
112. For a health professional to attend a scientific event overseas for which he/she has received an invitation (which must cover costs), he/she must undertake a 19–step authorization process that, in the extremely rare cases it is successful, takes around five months and involves interviews with State Security and the Communist Party plus at increasingly higher levels within the Ministry of Health, finally requiring approval by the Minister of Health. If authorized to travel abroad, they are rarely allowed to bring their families. (“Guía de trámites que debe realizar un médico que solicita asistir a un evento científico fuera de Cuba,” Diario de Cuba, undated (2010).)
113. Doctors serving abroad find creative ways to make money to complement their meager local stipends. Many offer private consultations for pay on the side. They compete for the assignments that will reap them greater material benefit—where they can maximize the savings from their stipend or purchase goods cheaply for resale in Cuba at large profit margins. South Africa is a choice assignment because the South African government makes additional direct payments in hard currency. As a result, allegations of corruption by Cuban government officials in charge of placement are not surprising. Under the table payments are said to be from US$500 to $1,000— a veritable fortune in Cuba. (“Unos 1.574 médicos cubanos en ‘misiones’ han huido a EE UU con visas de refugiados,” Diario de Cuba, 17 enero 2011.)
114. Many of these rules are spelled out in a hand-out given to each health worker titled “Disciplinary Rules for Doctors in Venezuela (Cuban Medical Collaboration with the Bolivarian Republic of Venezuela),” Copy obtained from a deserting doctor.
115. “Disciplinary Rules for Doctors in Venezuela,” op.cit.
116. For years the stipend was paid in the local currency (gourdes) and was only equivalent to US$100 (according to a 2004 report by the Cuban Ambassador to Haiti (W. Steif, op.cit.), a 2003 news report in Cuba News (Luxner, op.cit.) and as related by Lucas, 7/27/ 2011, op.cit.)
117. Internationalists had been allowed to send home 3 large boxes per year free of shipping costs and import duties (allowing their families to obtain electronics and consumer goods impossible to get domestically), but this benefit was suspended in 2010.
118. Gabriel Thimothe, Director General of the Haitian Health Ministry, told The Miami Herald in 2011 that the Cubans served in inaccessible areas. (Robles, op.cit.).
119. In Venezuela, for example, many Cuban health professionals have been assaulted, raped, or killed in Venezuela. In March of 2010, the Cuban and Venezuelan governments honored 69 Cuban doctors who had had died in Venezuela during their tours of duty in the previous seven years, presumably as a result of criminal acts. (“Reconocen muerte de 69 médicos cubanos en Venezuela,” El Universal, Caracas, 16 de abril, 2010.)
120. Dr. Joel de la Torre, op.cit.
121. Dr. Joel de la Torre, op.cit.
122. Lucas, 7/22/2011, op.cit.
123. Around 3,000 Cuban health professionals are believed to have defected from international missions worldwide in the last five years. Enrique Flor, “Cuba bloquea revalidación de títulos de odontólogos,”El Nuevo Herald, 11 julio 2011.) Many have staged dangerous and elaborate schemes to escape. From 2006 to through December 16, 2010, 1,574 visas had been issued by U.S. consulates in 65 countries pursuant to a special parole program established in 2006the “Cuban Medical Professional Parole Program” (CMPP), established in 2006 to grant entry to health professionals working in third countries under the direction of the Cuban government. Most defected from Venezuela and Bolivia, but others did so from Guatemala, Namibia, Peru and even far-flung countries such as Qatar, Fiji, Djibouti and Mauritius. (Joel Millman, “New Prize in Cold War: Cuban Doctors,” The Wall Street Journal, January 15, 2011.)
124. Many doctors who defected and are living in the U.S. reported to the autor that they have wives and children in Cuba who are not allowed out of the country to join them despite having entry visas to the U.S. The defecting doctors are also not allowed to enter Cuba. Many have not seen their families for years and have missed critical years of their children’s lives.
125. Lucas, by telephone, April 23, 2010.
126. This section draws on Werlau, op.cit. Details and sources are given in that earlier work.
127. Two recent examples are statements from the Medical Association of El Salvador and the Dean of Paraguay’s National University School of Medicine that graduates from Cuban medical schools did not meet the criteria to practice. (“Ante Denuncias: Ministerio de Salud Defiende a los Médicos Formados en Cuba,” El Diario De Hoy, 30 de Diciembre de 2010; Médicos cubanos tienen dificultades para ejercer en Estados Unidos, Agencias, Miami, Diario de Cuba, 28 marzo 2011.)
128. The bibliography on this topic is extensive. See www.CubaNet.org for almost daily reports from Cuba as well as the section “Selective Humanitarianism” in Werlau, op.cit.
129. Ironically, the same day the earthquake struck Haiti, a tragedy afflicted Cuba that, although not comparable in magnitude, is emblematic of the severe health crisis there. Dozens of patients died of hypothermia at Havana’s Psychiatric Hospital “Mazorra.” The facility was missing windows and the barely-clothed emaciated patients lacked blankets to confront a cold spell. The staff regularly the food and clothing destined for patients, who were regularly seen begging on the street. Pictures taken surreptitiously at the morgue show bodies in shocking malnourishment and with signs of abuse. After photos were leaked abroad, the government confirmed 26 deaths— independent sources reported many more—and some were eventually prosecuted. (See photos at www.therealcuba.com /Page10.htm and http://www.penultimosdias.com/2010/03/02/los-muertos-de-mazorra. See also: “Información a la Población, Ministerio de Salud,” Granma,16 de enero de 2010; Juan Tamayo, “Entre 40 y 50 los muertos en Hospital Psiquiátrico de La Habana,” El Nuevo Herald, 29 enero 2010.)
130. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women And Children, Supplementing the United Nations Convention Against Transnational Organized Crime. The Convention was adopted by resolution A/RES/55/25 of 15 November 2000 at the fifty-fifth session of the General Assembly of the United Nations and entered into force on December 25, 2003. Cuba ratified the Convention on 9 February 2007, but had not ratified the Protocol as of September 2010 (United Nations Treaty Collection, http://treaties.un.org.)
131. Early drafts of the Trafficking in Persons Protocol defined servitude as the status or condition of dependency of a person who is unlawfully compelled or coerced by another to render any service to the same person or to others and who has no reasonable alternative but to perform the service. (Combating Trafficking in Persons: A Handbook for Parlamentarians, United Nations, No. 16, 2009.)
132. “The status or condition of a person over whom any or all of the powers attaching to the right of ownership are exercised.” (League of Nations 1929 Slavery, Servitude, Forced Labour and Similar Institutions and Practices Convention.)