What The Hell America!

The four approaches of Cuban medical internationalism were initiated early in the 1960s, all despite the post-1959 departure of half of the physicians in Cuba.

1. Emergency response medical brigades. In May 1960, Chile was struck by the most powerful earthquake on record, with thousands killed. The new Cuban government sent an emergency medical brigade with six rural field hospitals. This established a modus operandi under which Cuban medics mobilize rapid responses to “disaster and disease” emergencies throughout the Global South — since 2005 these brigades have been organized under the name “Henry Reeve International Contingents.” By 2017, when the WHO praised the Henry Reeve brigades with a public health prize, they had helped 3.5 million people in twenty-one countries. The best-known examples include brigades in West Africa to combat Ebola in 2014 and in response to the COVID-19 pandemic in 2020. Within one year, Henry Reeve brigades treated 1.26 million coronavirus patients in forty countries, including in Western Europe.
2. Establishment of public health care apparatuses abroad. Starting in 1963, Cuban medics helped establish a public health care system in newly independent Algeria. By the 1970s, they had set up and staffed Comprehensive Health Programs all throughout Africa. By 2014, 76,000 Cuban medical personnel had worked in thirty-nine African countries. In 1998, a Cuban cooperation agreement with Haiti committed to send 300 to 500 Cuban medical professionals there all while training Haitian doctors back in Cuba. By December 2021, more than 6,000 Cubans medical professionals had saved 429,000 lives in the poorest country in the western hemisphere, conducting 36 million consultations. And for two decades now, Cuba has maintained over 20,000 medics in Venezuela, peaking at 29,000. In 2013, the Pan American Health Organization contracted 11,400 Cuban doctors to work in under- and unserved regions of Brazil. By 2015, Cuban Integral Healthcare Programs were operating in forty-three countries.
3. Treating foreign patients in Cuba. In 1961, children and wounded fighters from Algeria’s war for independence from France went to Cuba for treatment. Thousands followed from around the world. Two programs were developed to treat foreign patients en masse: The first is the “Children of Chernobyl” program which began in 1990 and lasted for twenty-one years, during which 26,000 people affected by the Chernobyl nuclear disaster received free medical treatment and rehabilitation on the island — nearly 22,000 of them children. The Cubans covered the cost, despite the program coinciding with Cuba’s severe economic crisis, known as the Special Period, following the collapse of the socialist bloc. The second program to treat foreign patients en masse was Operation Miracle, set up in 2004 for Venezuelans with reversible blindness to get free eye operations in Cuba to restore their sight. It subsequently expanded regionally. By 2017, Cuba was running sixty-nine ophthalmology clinics in fifteen countries under Operation Miracle, and by early 2019 over four million people in thirty-four countries had benefited.
4. Medical training for foreigners, both in Cuba and overseas. It’s important to note that the Cuban state never sought to foster dependence. In the 1960s, it began training foreigners in their own countries when suitable facilities were available, or in Cuba when they were not. By 2016, 73,848 foreign students from eighty-five countries had graduated in Cuba while that nation was running twelve medical schools overseas, mostly in Africa, where over 54,000 students were enrolled. In 1999, the Latin American School of Medicine (ELAM), the world’s largest medical school, was established in Havana. By 2019, ELAM had graduated 29,000 doctors from 105 countries (including the United States) representing 100 ethnic groups. Half were women, and 75 percent from worker or campesino families.

Since 1960, some 600,000 Cuban medical professionals have provided free health care in over 180 countries. The government of Cuba has assumed the lion’s share of the cost of its medical internationalism, a huge contribution to the Global South, particularly given the impact of the US blockade and Cuba’s own development challenges. “Some will wonder how it is possible that a small country with few resources can carry out a task of this magnitude in fields as decisive as education and health,” noted Fidel Castro in 2008. He did not, though, provide the answer. Indeed, Cuba has said little about the cost of these programs.

However, Guatemalan researcher Henry Morales has reformulated Cuba’s international solidarity as “official development assistance” (ODA), using average international market rates and adopting the Organisation for Economic Co-operation and Development (OECD) methodology, to calculate the scale of their contribution to global development and facilitate comparison with other donors. According to Morales, the monetary value of medical and technical professional services, Cuba’s ODA, was over $71.5 billion just between 1999 and 2015, equivalent to $4.87 billion annually. This means that Cuba dedicated 6.6 percent of its GDP annually to ODA, the world’s highest ratio. In comparison, the European average was 0.39 percent of GDP, and the United States contributed just 0.17 percent. Since the US blockade cost Cuba between $4 and $5 billion annually in this period, without this burden the island could potentially have doubled its ODA contribution.

These costs exclude Cuban state investments in education and medical training and infrastructure on the island. There are also considerable losses to Cuba from either charging recipients below international market rates or, in many cases, simply not charging them at all.

During “the Special Period” in the 1990s, Cuba introduced reciprocal agreements to share the costs with recipient countries that could afford it. Starting in 2004, with the famous “oil-for-doctors” program with Venezuela, the export of medical professionals became Cuba’s main source of revenue. This income is then reinvested into medical provision on the island. However, Cuba continues to provide medical assistance free of charge to countries who need it. Today there are different cooperation contracts, from Cuba covering the full costs (donations and free technical services) to reciprocity agreements (costs shared with the host country) to “triangulated collaboration” (third-party partnerships) and commercial agreements. The new measure announced by Rubio will impact them all.

In 2017, Cuban medics were operating in sixty-two countries; in twenty-seven of those (44 percent) the host government paid nothing, while the remaining thirty-five paid or shared the costs according to a sliding scale. Where the host government pays all costs, it does so at a lower rate than that charged internationally. Differential payments are used to balance Cuba’s books, so services charged to wealthy oil states (Qatar, for example) help subsidize medical assistance to poorer countries. Payment for medical service exports goes to the Cuban government, which passes a small proportion on to the medics themselves. This is usually in addition to their Cuban salaries.

In 2018, the first year Cuba’s Office of National Statistics published separate data, “health services exports” earned $6.4 billion. Revenues have since declined, however, as US efforts to sabotage Cuban medical internationalism have succeeded, for example in Brazil, reducing the island’s income by billions.

Already in 2006, the George W. Bush administration launched its Medical Parole Program to induce Cuban medics to abandon missions in return for US citizenship. Barack Obama maintained the program until his final days in office in January 2017. By 2019, Trump renewed the attack, adding Cuba to its Tier 3 list of countries failing to combat “human trafficking” on the basis of its medical internationalism. The US Agency for International Development (USAID) even launched a project to discredit and sabotage Cuban health care programs. In 2024, the US House Committee on Appropriations bill included exposing the “trafficking of doctors from Cuba,” withdrawing aid from “countries participating in this form of modern slavery,” and prohibiting funds to Cuban laboratories. Meanwhile it allocated $30 million for “democracy programs” for Cuba, a misnomer for the regime change that Mallory strategized in 1960.

The service contracts that Cuban medics sign before going abroad are, in fact, voluntary; they receive their regular Cuban salary, plus remuneration from the host country. The volunteers are guaranteed holidays and contact with families. Whatever their motivations to participate, Cuba’s medical professionals make huge personal sacrifices to volunteer overseas, leaving behind families and homes, their culture and communities, to work in challenging and often risky conditions for months or even years. Interviewed for our documentary, Cuba & COVID-19: Public Health, Science and Solidarity, Dr Jesús Ruiz Alemán explained how a sense of moral obligation led him to volunteer for the Henry Reeve Contingent. He went on his first mission to Guatemala in 2005, West Africa for Ebola in 2014, and to Italy in 2020 when it was the epicenter of the COVID-19 pandemic. “I have never felt like a slave, never,” he insisted. “The campaign against the brigades seems to be a way to justify the blockade and measures against Cuba, to damage a source of income for Cuba.”

In the same documentary, Johana Tablada, deputy director for the United States at Cuba’s Ministry of Foreign Affairs, condemned the “weaponization and criminalization” of Cuban medical internationalism that has “wreaked havoc,” particularly in countries pressured to end their partnerships with Cuba shortly before the COVID-19 pandemic, such as Brazil and Bolivia. “The reason that the US calls it slavery or human trafficking has nothing to do with the international felony of human trafficking.” This is cover, she says, for a policy of sabotage that is “impossible to hold up to public scrutiny.” The United States cannot tell people in developing countries to give up medical services provided by Cuban medical brigades “just because it doesn’t match their policy to have international recognition and admiration [for Cuba].” The US is certainly not offering to replace Cuban doctors with its own.

The predominant global approach, exemplified by the United States, is to regard health care as an expensive resource or commodity to be rationed through the market mechanism. Medical students “invest” in their education, paying high tuition fees and graduating with huge debts. They then seek well-paid jobs to repay those debts and pursue a privileged standard of living. To ensure medics are well remunerated, demand must be kept above supply. The World Economic Forum projects a shortfall of ten million health care workers worldwide by 2030. But the Cuban investment in medical education raises the supply of professionals globally, thus threatening the status of physicians operating under a market system. Critically, the Cuban approach removes financial, class, race, gender, religious, and any other barriers to joining the medical profession.

The key features of the Cuban approach are: the commitment to health care as a human right; the decisive role of state planning and investment to provide a universal public health care system with the absence of a parallel private sector; the speed with which health care provision was improved (by the 1980s Cuba had the health profile of a highly developed country); the focus on prevention over cure; and the system of community-based primary care. By these means, socialist Cuba has achieved comparable health outcomes to developed countries but with lower per capita spending — less than one-tenth the per capita spending in the United States and one-quarter in the UK. By 2005, Cuba had achieved the highest ratio of doctors per capita in the world: 1 to 167. By 2018, it had three times the density of doctors in the US and the UK.

Today Cuba is in the midst of a severe economic crisis, largely resulting from US sanctions. The public health care system is under unprecedented strain, with shortages of resources and of personnel following massive emigration since 2021. Nonetheless, the government continues to dedicate a high proportion of GDP on health care (nearly 14 percent in 2023), maintaining free universal medical provision, and currently has 24,180 medical professionals in fifty-six countries.

Revolutionary Cuba was never solely concerned with meeting its own needs. According to Morales’s data, between 1999–2015 alone, overseas Cuban medical professionals saved 6 million lives, carried out 1.39 billion medical consultations and 10 million surgical operations, and attended 2.67 million births, while 73,848 foreign students graduated as professionals in Cuba, many of them medics. Add to that the beneficiaries between 1960 and 1998, and those since 2016, and the numbers climb steeply.

The beneficiary nations have been the poorest and least influential globally; few have governments with any leverage on the world stage. Recipient populations are often the most disadvantaged and marginalized within those countries. If Cuban medics leave, they will have no alternative provision. If Rubio and Trump are successful, it is not just Cubans who will suffer. It will also be the global beneficiaries whose lives are being saved and improved by Cuban medical internationalism right now.