“Healthcare without Borders”: Medicine as the Face of Cuban Soft Power

By Jack Englehardt

For an island about the size of Austria, and only slightly more populous, Cuba punches far above its weight in the realm of international relations. Its celebrity – some would say infamy – is the product of a long struggle to balance its own sovereignty against overwhelming pressure from outside interests. Though its heritage as the vanguard of communism has faded since the tumult of the 1960s, Cuba still contends with the punitive bloqueo imposed by the United States in the island’s revolutionary youth. Pinned between Khrushchev and Kennedy, Cuba appears to the casual observer as an aging relic – an unspoiled paradise of classic cars and white sand beaches reaching toward an azure horizon. Yet beneath its placid façade lies a Cuba which is far more than the sum of its historical allegiances.

There is one particular field in which Cuba continues to be an international bellwether, comparable even to the first-rate economies of Europe: healthcare. On nearly every indicator of health and wellness, Cuba consistently outperforms nations an order of magnitude wealthier than itself. Cuba has a lower infant mortality rate (4.76 per 1,000 live births) than Canada (4.78), a life expectancy (78.05 years) on par with Denmark, and an HIV prevalence rate only one-sixth that of the United States; all this in a country whose average monthly salary is a mere $25 – an American earning the federal minimum wage earns as much in under four hours. That a middling state should achieve this standard while hermitically sealed from its hemisphere’s pharmaceutical hegemon is all the more reason to recognize Cuba as a stunning model of medical achievement.

Cuba’s remarkable national wellbeing is the direct result of decades of investment in a robust state health service with a major focus on preventative medicine. Generous subsidies for medical education have allowed Cuba to field 6.7 physicians for every 1,000 people, three times as many as the United States (2.4) and Canada (2.1) and more than twice that of the United Kingdom (2.7). This exceptional reservoir of talent has allowed Cuba to export its trained physicians to countries in need – part of an ambitious program of medical assistance which will be the principal focus of this article.

The scope of Cuba’s ‘medical internationalism’, which involves some 25,000 doctors (a full third of the country’s total) and a further 30,000 medical support staff, is without equal anywhere in the world. Supplementing this field work, Cuban professors have established medical schools in over a dozen countries from Haiti to Timor-Leste, training a generation of 20,000 foreign physicians. Yet the manifold achievements of this humanitarian regime are little-studied in Western scholarship. Through a critical retelling of Cuba’s sixty-year pursuit of ‘healthcare without borders’, this article aims to grant long-deserved recognition to one of the world’s most productive international development strategies.

Cuba’s fixation on humanitarian goodwill is firmly rooted in the island’s turbulent history. The Marxist guerillas who, in 1959, overthrew the US-backed Batista regime and installed a leftist government, considered themselves only the most recent in a long heritage of Cuban rebels. Their dramatic combat echoed the war against Spain 60 years earlier, in which a legion of idealistic foreigners – Dominicans, Americans, Canadians, and even Poles – had volunteered to realize the project of Cuban statehood. A debt was owed to the international community, and newly-enlightened Cuba felt it was finally in a position to pay. As the world had once led Cuba into independence, Cuba would now lead the world into a post-liberal, communist world order. The poster child of this nascent internationalism was the doctor-cum-liberator Che Guevara, whose model of a socially conscious, Marxist “new man” called on those with specialized knowledge to aid the revolution worldwide. Thus, it was with a sharply ideological edge that Cuba’s first medical brigade left for Chile in 1960.

Through the remainder of the Cold War, Cuba projected its Marxist bona fides more aggressively than any country of its size in the Soviet bloc. These first detachments of medical personnel were not uncommonly escorted by Cuban soldiers, who effectively served as mercenaries for the worldwide communist insurgency. This occurred most notably in Angola, where 50,000 Cuban soldiers were sent to advance the cause of Marxist revolution. Yet the military dimension of Cuba’s foreign policy faded with the demise of the Soviet Union, whose financial and logistical support could not easily be replaced. Without abandoning its narrative of South-South cooperation, Cuba began to emphasize the medical dimension of its international development agenda. Following the nuclear disaster at Chernobyl, its doctors treated 20,000 children for radiation-related illnesses free of charge. When Haiti was devastated by an earthquake in 2010, Cuban doctors were the first foreigners to respond, providing complex surgeries, neonatal care, tetanus vaccinations, and mental health resources for Haitians in every one of the country’s ten departments.

The political advantages to such a generous humanitarian outlook are obvious. From its position of great moral influence, Havana has been able to translate its goodwill into direct diplomatic support and material capital. Thanks in large part to its highly visible disaster response efforts, Cuba has evolved from a one-time international pariah into a middle power with considerable pull in the United Nations. Its diplomatic renaissance is displayed most dramatically in the annual UN resolution condemning the American blockade, which in 2014 garnered 188 votes in favor and only two against (the US and Israel, with Palau, Micronesia, and the Marshall Islands abstaining). Cuba’s medical internationalism is a classic demonstration of ‘soft power’ – a term coined by Joseph Nye to describe the ability of nations to solicit support through positive, cooperative action rather than brute force and intimidation.

Medical aid also provides very real material advantages for the Cuban state. The stipends paid to Cuban doctors by host countries amount to $8 billion annually, almost three times the amount earned through tourism. The promise of hard currency has made medical services a leading sector within the export-starved Cuban economy, and a pillar of the nation’s future fiscal outlook. Transnational medical services are also a key component of the Alternativa Bolivariana para los Pueblos de Nuestra América (ALBA), a partnership between leftist states which has seen Cuba lend significant resources to illiberal but strategically valuable regimes in Latin America. Venezuela, a key regional ally of Cuba, is the single greatest recipient of medical aid, as part of its lucrative oil-for-doctors trade agreement. Though Cuba’s foreign policy has become progressively more conciliatory in the post-Soviet world, medical services still serve an important strategic and economic utility for the state.

This is not to suggest that medical internationalism is an entirely self-serving political maneuver; only that all foreign policy is grounded in a necessary cost-benefit calculus. Cuba’s provision of doctors to regions broken by Western military adventurism is of undeniable symbolic value, but it also speaks to a deeper ideological commitment to the advancement of global health. Cubans have long understood that targeted, institutional health reform is more productive than glitzy but short-term development packages – one of the many reasons they prefer the term ‘medical cooperation’ to the paternalistic ‘medical aid’. Working in areas both remote and treacherous, Cuban doctors live among the people they serve, making themselves available for house calls at all hours with no cost to the patient. Constant positive interaction with so many foreign health professionals challenges societal values and causes host populations to re-evaluate the structure and functionality of their own health systems. The case of the small Pacific island of Nauru illustrates  the transformative impact of even modest medical investment – the handful of Cuban physicians sent there in 2004 comprised, for a time, 78% of all doctors in the country.

One of the great accomplishments of the Cuban health regime has been the Escuela Latinoamericana de Medicina (ELAM), founded in 1998 as a response to the devastation caused by Hurricane Mitch in Central America and the Caribbean. The school’s six-year medical program is provided entirely free of charge for low-income international students, so long as they commit to practicing medicine in underserved communities upon graduation. As an experiment in long-term medical education, ELAM and its constellation of sister schools have been extraordinarily successful in equipping poor countries with a productive and socially conscious indigenous health infrastructure.

Havana has also routinely dispatched emergency specialists to nations who could not possibly serve its strategic interests, including several countries which did not even recognize the legitimacy of the Cuban state. When a massive earthquake ravished Managua in 1972, Cuban doctors were among the first on the scene, even though the Nicaraguan president was a sworn adversary of the Cuban revolution. Even more stunning, Cuba offered to send more than 1,000 doctors to the United States in the aftermath of Hurricane Katrina, despite enduring a half-century of American hostility and economic warfare (the offer was ultimately refused by the Bush administration). John M. Kirk, a leading scholar of medical diplomacy, rightly claims that, while medical exports are undeniably a strategic asset, “humanitarian solidarity has consistently triumphed political considerations” in the lexicon of Cuban foreign policy.

At its core, the Cuban campaign to raise a new generation of health professionals in the Global South is a highly distinctive approach to international relations that eschews market-based strategies and instead incorporates meaningful social development for the world’s most underserved communities. Cuba is attempting not just to replicate its own success in forming a cost-effective health system, but to fashion an entirely new development logic founded on Marxist notions of international solidarity and socially responsible medical care. Cuban internationalism has proven over sixty years that it is one of few development strategies capable of breaking the hegemonic cycle of dependency and neo-colonialism, serving the interests of both host and benefactor while making room for indigenous growth.   

Still, despite its phenomenal success in combating global suffering, medical internationalism is only an afterthought to the Western-dominated development community. Financed without World Bank funds, or the sponsorship of any major corporation or private foundation, Cuba’s global health campaign has been criminally overlooked. Whatever your opinion on the oft-maligned Castro regime, it has, under great adversity, achieved nothing short of a public health miracle both at home and abroad. Cuba has demonstrated with singular success that even a poor, politically isolated country is capable of attainting first-rate human health care, and that global medicine is a more productive development strategy than global capital. In the interests of honestly addressing endemic poverty and preventable death in the world’s poorest regions, we must recognize medical internationalism for what it is – Cuba’s single greatest export to the wider world.

The views expressed in this article are the author’s own, and may not reflect the opinions of the St Andrews Economist. 

Photograph taken by Roel Coutinho

References

Feinsilver, Julie M. “Fifty Years of Cuba’s Medical Diplomacy: From Idealism to Pragmatism.” Cuban Studies 45 (2010): 85-104.

Grenon, Marie Michèle. “Cuban Internationalism and Contemporary Humanitarianism: History, Comparison and Perspectives.” International Journal of Cuban Studies 8, no. 2 (2016): 200-216.

Huish, Robert, and Sarah A. Blue. “Understanding the Place of Cuban Internationalism.” International Journal of Cuban Studies 5, no. 1 (Spring 2013): 6-9.

Kirk, John M. Healthcare Without Borders: Understanding Cuban Medical Internationalism. Gainesville: University Press of Florida, 2015.

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