Humanitarianism and Solidarity Cuban-Style
It has been widely recognized that Cuba has a remarkably effective health-care system for a relatively poor third world country. This fact is becoming even more widely known thanks to Michael Moore’s documentary Sicko. As a result, Cuba has health indicators comparable to its far wealthier neighbor. For example, life expectancy in Cuba is 77.5 years, in the U.S. it is 78. Cuba’s infant mortality rate is 5.3 deaths among 1,000 live births in the first year, whereas in the U.S. it is 6.9 (according to 2003 figures, the last year for which data have been compiled). In Mississippi infant mortality is 11.4 and as high as 17 among blacks, and rising. In our nation’s capital, infant mortality is 14.4 among African Americans.
Even the World Bank has had to acknowledge Cuba’s achievements in health and education. Their 2001 edition of “World Development Indicators” showed Cuba as topping virtually all other poor countries in health and education statistics. Former Bank President James Wolfensohn congratulated Cuba for doing “a great job” in providing for the social welfare of the Cuban people.
How is this possible? How has a poor country that lacks the medical technology we have, and even has difficulty getting basic equipment and medicines due to the U.S. blockade, been able to take such good care of the health of its population? The answer is doctors. Cuba has 5.3 doctors per 1,000 people—the highest ratio in the world and nearly double that of the U.S. The secret to Cuba’s success is the 60,000 dedicated physicians and other health professionals, plus a system based on the principle that health care is a right rather than a commodity for sale. Cuba provides free universal health care accessible to all of its people. Doctors live in every neighborhood where they practice comprehensive, community-based, preventative care. In every neighborhood there is an easily recognizable house where the doctor lives on the second floor, the first floor being his office. So a doctor is available, close at hand, every day and he or she (half of the nation’s doctors are women) makes house calls, too. Also, not far away, there is a polyclinic. More specialized care is provided by larger municipal hospitals.
It wasn’t always like this. After its Revolution in 1959, half of the nation’s doctors followed their affluent patients to Miami. So from the beginning the government had to make great efforts to educate new doctors. Today, there is a major medical school in every province. The country now graduates 3,500 doctors a year, far more than required for its population of 13 million.
What does Cuba do with its vast surplus of doctors? It sends them to serve abroad in poor countries. Cuba has long been generous in sharing its medical advances with third world countries. In fact, it has more doctors serving abroad than the World Health Organization. Since 1963, 100,000 doctors have served in 101 countries. Currently, Cuba has a large medical mission in South Africa, and with the Chavez government in Venezuela as well as the Morales government in Bolivia. Altogether this small country has more than 30,000 health-care professionals cooperating in 68 countries, according to the Cuban Minister of Public Health, Jose Ramon Balaguer Cabrera. In addition, Cuba is training 20,000 health-care professionals from 26 countries and carrying out special initiatives such as Operation Miracle, which has returned sight to more than a half million Latin Americans.
In fact, Cuba has emerged as a medical superpower. Even during the severe economic depression in the 1990s, Cuba devoted 9.1 percent of its gross domestic product (GDP) to health. Currently, it spends 6.3 percent of its GDP.
After Hurricane Mitch devastated much of Central America in November 1998, Cuba sent medical teams to provide emergency relief. They went into the more remote areas, bringing medical care to people who had little access to a doctor even in normal times. The results were spectacular. In Guatemala the infant mortality rate dropped from 40 per 1,000 live births to 18.6—a figure directly attributable to the work of the Cubans, according to the Guatemalan ambassador to Cuba, Hugo Guzman. Similar successes have been logged in Honduras, as well as in areas of Africa.
Immediately after Hurricane Katrina hit New Orleans in 2005, Cuba offered to send doctors to help its victims. Within hours, over 1,000 doctors with backpacks of emergency supplies were ready to fly to Houston, but the Bush administration ignored the offer. Cuba repeated the offer several times and the number of qualified and experienced physicians who volunteered grew to 1,586. This became the basis for the formation of the Henry Reeve contingent of humanitarian doctors prepared to provide assistance in disaster situations and epidemics. They have since gone to Pakistan where they were the largest medical assistance effort following its earthquake. Altogether, 2,300 medical professionals performed operations on 1.7 million patients. Today, the Henry Reeve Contingent, the first of its kind, stands ready to bring emergency medicine to a world in need of cooperation and solidarity.
But Cuba has gone beyond simply providing humanitarian relief in emergencies. Recognizing the need to do something on a more long-term basis, Havana decided to offer young people from the poorest regions of Latin America and Africa the chance to become doctors themselves. The unwritten commitment of each and every student is to return to their country and practice their skills for a period of ten years in the poorest and most needy of their communities, thereby replacing the Cuban doctors. Thus was born the Latin American School of Medicine (ELAM). Opening in 1999, it is located on the western edge of Havana in a former naval base. ELAM educates young people from 29 different nations and 67 different ethnic and cultural groups to become doctors, medical technicians, and other health-care specialists. The director, Juan Caresa, told us there are currently 10,200 students. Among them are 91 low income students from the U.S., 8 of whom were among the 1,550 students who graduated this July, plus 18 new minority students from the U.S. who arrived in August.
Most of the students would have found it impossible to study medicine at home without the financial grant they obtained from Cuba. The six-year course provides everything: lodging, clothing, food, books, and a small amount of spending money. ELAM teaches values as well as techniques. Their training combines “science and a humane sensibility, science and social consciousness,” as Dr. Caresa put it. The idea is that society provides a medical education and the doctor in turn owes an obligation to give back to society. His or her knowledge is not their private property, enabling them to get rich. As Carmen Landau of Oakland, California, one of this year’s U.S. graduates, told Reuters, “Cuba offered us full scholarships to study medicine here. In exchange, we commit ourselves to go back to our communities to provide health care to underserved people.”
Cuba’s growing partnership with Venezuela has enabled it to greatly expand its humanitarian missions abroad. This is illustrated by the Operation Miracle program, initiated in July 2004 in which Cuban hospitals gave free eye surgery to poor Venezuelans who were brought there by Hugo Chavez’s government. By the fall of 2006, 290,000 Venezuelans had their sight restored. Similar surgical facilities have now been set up in other nations under the supervision of Cuban medical personnel and financed by Venezuelan oil revenue. Today, 13 ophthalmologic centers are in service in Venezuela, and similar facilities are providing services in Ecuador, Guatemala, Haiti, Honduras, and Bolivia. Professor Lazaro Vigoa of the Instituto Cubano de Oftalmologia told us that to date over 600,000 people from 29 nations have benefited from Operation Miracle. On January 22, 2006, Cuban President Fidel Castro offered free eye surgery for 150,000 poor U.S. citizens, including air transportation and their accommodations on the island. It is unlikely the Bush administration will allow that to happen.
Reforming Medical Education
Cuba is now pioneering a new approach to medical education. Instead of starting their education in the classroom with courses in anatomy and the sciences, students are sent into the field to work with primary care physicians, later going into classes to learn the scientific underpinnings of what they have practiced. This approach was developed under the leadership of Ruben Zardoya, formerly dean of the faculty of philosophy and history at the University of Havana. In 2001 he was tapped to head up a new school of social work that trained unemployed youth to become social workers in their communities. After quickly solving the problem of youth unemployment, the school went on to train thousands of Venezuelan youth as well.
Then in 2005 Zardoya initiated the program to develop field-based medical education. He went to Cienfuegos with 900 students from Guatemala, Bolivia, and Venezuela where they turned an unused rural school into a medical school. He lived there for four months, overseeing the creation of this new program. Later the city of Holguin took on 1,500 students from Bolivia who stayed in the homes of local people. To date 60 rural schools have been renovated across the island and turned into medical schools with 450 students each.
This approach to medical pedagogy is a natural outgrowth of Cuba’s community-based health-care system. Whether at home or abroad, Cuban doctors live close to the people they serve. They become part of the community and take responsibility on a personal basis for public health and education.
Community-based medical education was the germ of what has become the Sandino Commitment, a bilateral agreement between Venezuela and Cuba announced in April 2007. This project aims to train 200,000 Latin American doctors over this decade. Like the students in ELAM, more than being trained in medicine, these doctors will be prepared with a high sense of social commitment—motivating them to care for the peoples of the region wherever they are needed, says Hugo Chavez. Venezuela is now inaugurating its own Latin American School of Medicine, similar to the one in Cuba, using the new approach to medical education. Havana’s ELAM is also incorporating their new approach into its curriculum, according to its director.
There is one other program that warrants brief mention among Cuba’s humanitarian missions. That is its innovative literacy program. Immediately after the triumph of the Revolution in 1959, Cuba embarked on a literacy campaign, sending young people into the most remote areas of the country to teach reading and writing. The success of this effort in wiping out illiteracy made the Cuban approach a model hailed by UNESCO. It laid the foundations early on for the impressive educational accomplishments of the past decades.
Now Cuba has developed a new pedagogy for teaching literacy called Yo Si Puedo (Yes, I Can). In 2006 UNESCO again awarded Cuba its literacy prize for this new method. It is currently being used in 16 countries to teach over 580,000 people how to read and write in just 7 weeks. In June I visited the school in Havana where the method was developed. The Pedagogical Institute of Latin America and the Caribbean (IPLAC) has also developed a follow up program that takes students to a ninth grade reading level. In Venezuela Yo Si Puedo has reached two million people and made the country virtually illiteracy free. There is even a project in Mexico called MECE.
Yo Si Puedo is another component in ALBA in which the countries of Latin America are helping each other cooperatively develop using their own human resources.
Cuba also has thousands of teachers serving abroad and foreign students studying on scholarship in Cuba. Cuba is reversing the brain drain from the third world. Unlike the U.S., which is attracting educated and technically trained people away from poorer countries where they are desperately needed, Cuba is contributing to the development of these capacities in the third world. In the U.S., some 50 percent of foreign students who receive doctorates remain to work in the U.S. For instance, there are more Ethiopian doctors in Chicago than in all of Ethiopia. By contrast, Cuba encourages, even requires, those whom it educates to return to their countries so they can help the under-serviced communities they come from.
The question remains: how is a relatively poor country like Cuba able to do so much? Why does it do it? There are obvious foreign policy benefits to Cuba. Its humanitarian solidarity with the poor in the global South wins popular support for Cuba. For example, after recovery from Hurricane Mitch, the Honduran government sent the Cuban doctors home. There was so much popular protest against this from rural communities who had never seen a doctor until the Cubans came, that the government had to invite them back. On the other hand, in Venezuela the doctors protested the presence of Cuban doctors who were threatening to break their monopoly over health care in the country, even though the Cuban doctors served in poor barrios where the Venezuelan doctors feared to go.
There are also important economic benefits to Cuba. While most of its services to poor countries are given free, there are also countries like China who are able to pay and do. Then, too, there are mutually beneficial exchanges with other countries under ALBA. In return for the large number of doctors and teachers Cuba sends to Venezuela, it is able to buy oil at below market prices. Both countries benefit as a result. However, this is not seen as a purely commercial agreement and no one seems to know how Cuba monetarizes the services it provides.
However, Fidel Castro did recently reveal an interesting fact when he stated in a speech “The health-care system has become the most important sector in the exchange of goods and services between our country and the rest of the world in economical terms; but despite this Cuba has not failed to offer its medical assistance completely free of charge to more than 60 third world countries lacking economic resources. That is how it has always been and how it always will be” (September 19, 2005).
Usually Cuba’s humanitarian missions are presented in terms of ideals of solidarity with the peoples of the world. For instance, at a Cuban airport you might see a huge banner proclaiming “Nuestra pais es humanidad.” This quote from Jose Marti is not just empty rhetoric. The Cuban people are very humanistic and interna- tionalistic minded. My colleague, Jualynne Dodson, who has been doing anthropological field research in Cuba for years, suggests that this comes in part from the influences of African traditions in Cuban culture. These traditions value service to others and see that we all have a responsibility to make the world a better place than we found it.
This is a far cry from the values of conquest and greed that the Spanish conquistadors brought to Cuba. Fortunately, it was not those values that shaped Cuba’s national culture. Instead, the African origins of most of its population blended with and reinforced the humanitarian strain in the European-based culture that Spaniards and others brought to the island. These values have been nurtured in a century and a half of national struggle for independence and dignity. They constitute a universal legacy vital to making a better world possible and greatly admired by all those who have come to know Cuba well.
Cliff DuRand is a research associate at the Center for Global Justice (www.globaljusticecenter.org) and professor emeritus of philosophy at Morgan State University. He leads an annual Research Network in Cuba (www. cubaconference.org).