By Haley Wiebel, Research Associate at the Council on Hemispheric Affairs
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Although its role as a pariah state in the eyes of the U.S. government has contributed to its underdevelopment as a nation, Cuba has emerged an unlikely victor in health care. The Cuban Revolution served as a catalyst for improved medical services and universal treatment on the island. Although Fidel Castro’s vision for a Cuba mejor stemmed from his political mantra, the country’s most successful social program can ultimately be credited to the medical training of former revolutionary Che Guevara. Still, a cursory review of Cuba’s economy would suggest a lack of social institutions altogether. Exporting Guevara’s legacy in an effort to gain international recognition, Castro used the country’s unique medical prototype as a diplomatic tool beginning in the 1960s. The increasing supply of Cuban doctors allowed some of the most underdeveloped parts of the world to begin receiving medical professionals as well as new clinics. The Cuban health care system, therefore, has revolutionized the implications of domestic social development.
As a young man, Castro developed a profound interest in social justice. Attending law school fueled his desire to become an advocate of reform. Furthermore, once he became involved in the island’s anti-communist party Partido Orthodoxo, Castro began building his political platform on social change.[i] He soon gained political momentum, motivating his decision to run for parliament in 1952.[ii] However, Castro’s vision was temporarily crushed after Fulgencio Batista scrapped all elections through a coup. Associated with crime and corruption, Batista allowed social and economic disparity to widen under his rule. Castro became increasingly frustrated by the worsening conditions in Cuba: “[Many of the sugar cane workers were] living on the margins of survival […] Neither health care nor education reached those rural Cubans at the bottom of society.”[iii] Although Castro came from a middle-class family, he understood rural poverty because he spent his early childhood in the countryside. Thus, Castro’s campaign as a revolucionario was intensified by his disdain for Batista and his belief in improving society. Castro’s rhetoric following his dissident 1953 attack on Moncada Barracks underscored his belief in providing improved institutions: “Cuba could easily provide for a population three times as great as it has now, so there is no excuse for the abject poverty of a single one of its present inhabitants […] What is inconceivable is that […] children should die for lack of medical attention.”[iv] Thus, Castro’s History Will Absolve Me speech unveiled part of his reformist agenda: his belief in universal health care on the island as a major form of social progress.
Following the Cuban Revolution, Castro began to mold a political framework consistent with the revolutionary impact of health care. He guaranteed free elections after he ousted Batista in 1959.[v] However, the young leader broke his promise, resorting to absolute power to restructure the nation. In the absence of democracy, the United States condemned his plan to develop Cuba. Castro challenged western paradigms of modernization at the time, in an era in which development efforts were motivated by Cold War sentiment. Rather than relying on Western standards, Castro used his intimate knowledge of Cuba’s impoverishment to construct the nation’s own development model: “From the initial days of the revolutionary government, Cuba’s leaders espoused universal health care as a basic human right and the responsibility of the state.”[vi] Castro’s ideology surrounding health care became cemented into Cuban law by 1976.[vii] Article 50 of the Cuban Constitution highlights the role of the state in providing equal access to health care: “Everybody has the right to health protection and care. The State guarantees this right by providing free medical and hospital care by means of the installations of the rural medical service network, polyclinics, [and] hospitals.”[viii] Under Castro’s leadership, “[the government] absorbed all private insurance programs, health care services, and hospitals into a national public system. Prices for medicine were reduced and pharmaceutical companies were nationalized.”[ix] Castro used authoritarianism to support his belief in the continued relevance of the Revolution. Thus, he believed that Cuban health care not only served as a validation of the state, but also his leadership abilities: “Cuban leaders consider health indicators to be measures of government efficacy, and as a result, health care has assumed an inordinately prominent place in Cuban government policies.”[x] Cuban domestic politics built the foundation of the country’s modern health care system, ensuring Castro’s stronghold of control.
Although Castro created the political mechanism that enforced his vision, Che Guevara influenced the effectiveness of the health care system itself. Castro and Guevara shared the same vision: to create Cuban solidarity through advanced health care.[xi] Guevara’s advocacy of universal medical treatment stemmed from his own training as a physician and travels across Latin America.[xii] His 1960 speech On Revolutionary Medicine, explains how witnessing social disparity shaped his future involvement in Cuba: “I began to travel throughout America […] I came into close contact with poverty, hunger and disease; And I began to realize at that time that […] I wanted to help those people […] I began to investigate what was needed to be a revolutionary doctor.”[xiii] Guevara’s redefined ideology made him a strong advocate of rural medical care. Despite his ambitions, half of the island’s doctors left immediately after the Cuban Revolution as a result of the new government.[xiv] Undoubtedly influenced by Guevara, Castro quickly responded by reopening the University of Havana Medical School; The Ministry of Public Health also established the Rural Health Service, a domestic volunteer program for doctors.[xv] Thus, Guevara’s advocacy began to materialize: “The government started by enlisting 750 physicians and medical students for a period of their professional lives to work in the mountains and coastal communities.”[xvi] Guevara essentially created mobile medical units. Those who were unable to reach the cities’ developing health care facilities due to their own poverty or immobility were not discriminated against, but rather were given equal medical attention.[xvii] Thus, Guevara’s ideology provided Castro with a roadmap for some of the most successful aspects of his social program.
Furthermore, Castro’s health care innovations became a model for development during the late 20th century. Using free education as an incentive for medical students, Castro’s government ensured that the number of medical training facilities could accommodate the supply and demand of health care professionals.[xviii] Medical and nursing schools were built in Cuba’s provinces, encouraging locals to serve their own communities.[xix] As a result, Castro created a medical workforce that remains unrivaled by any other developing nation: “[In 2008, Cuba had] about 33,000 family physicians. Specialization in family medicine is a requirement for more than 97% of medical graduates.”[xx] His model relied heavily on community polyclinics, which were first established in 1974; the Cuban government continues to believe that workers can efficiently practice medicine if they understand the social conditions of their site.[xxi] Serving as an alternative to large hospitals, polyclinics have offered specialized care to communities. As a result, residents can easily access professionals such as gynecologists and pediatricians without traveling to an urban center.[xxii] Cuba has continued expanding its medical services and technology over time, making the country a hub for organ transplants, heart bypasses, and other complex surgeries.[xxiii] Thus, by the 1980s, Cuba boasted rival health indicators in relation to developed countries: “In 1982 Cuba’s infant mortality rate […] was  points lower than the average rate for all developing nations […] life expectancy at birth in Cuba was surpassed by only Japan, Sweden, Switzerland, Denmark, Iceland, the Netherlands, and Norway, being equaled by the United States”[xxiv] While Castro’s health care program appeared relatively intuitive during its early stages, it later became recognized as a development phenomena throughout the world. Castro’s 1992 speech, Health Care at Ameijeras Hospital, conveys Cuba’s developmental paradox: “I am sure that in no other country in the world do all the citizens have the same rights and the same possibility of receiving top health care as in Cuba.”[xxv] Thus, Guevara and Castro’s simple steps for lessening poverty and disparity gave rise to Cuban medical internationalism.
Although Cuban medical diplomacy originates from Guevara and Castro’s shared ideology regarding poverty, political circumstances have shaped the country’s international development efforts. During the Cold War, Castro became embroiled in the U.S. and Soviet Union’s battle for hegemonic power; given Cuba’s strategic location, both countries wanted influence over the island. In an effort to gain international recognition and to appease its northern neighbor, Castro visited Washington, D.C. in 1959.[xxvi] Yet, Castro’s trip only worsened the U.S.’s fear of the spread of communism in Cuba, resulting in tense relations. After the U.S. enacted the 1961 Trade Embargo, Castro found himself isolated from the West, which he used to his advantage.[xxvii] Although he instituted the first medical brigade in 1960, in response to a Chilean earthquake, health care became a way for Castro to appeal to foreign governments that shared a similar distrust of the West.[xxviii] Moreover, Cuba’s role in the Cold War demanded the need for international allies: “Havana began in the early 1970s to expand its foreign policy perspectives beyond these narrow Cold War parameters by interjecting a stronger South/South dimension into its international agenda.”[xxix] Countries throughout Latin America, Africa, and the Caribbean began receiving increased medical assistance as a result. Furthermore, Castro believed that health care diplomacy would spread the ideals of the Cuban Revolution and give non-western governments increased agency from Western influence: “Cuban revolutionaries from the very beginning felt an obligation to show ‘solidarity with their brothers’ and go wherever in the world fellow human beings were in medical need […] Washington accused Cuba of exporting revolution.”[xxx] Moreover, the nation’s involvement in Algeria during the 1960s exemplifies the complex political forces behind Cuban medical internationalism. As Algeria remained one of the last French colonies fighting for independence in Africa, Cuba offered rebel groups medical and military assistance.[xxxi] Cuba was struggling economically at the time; however, Castro believed that Algeria’s cause embodied the ideals of the Revolution.[xxxii] Algeria served as Cuba’s first medical assistance project abroad that did not involve disaster relief. After securing independence from France in 1963, Algeria relied on Cuban health care professionals. Many of its own doctors had returned to Europe: a testament to the power of the Cuban health care model.[xxxiii] Castro deployed 56 doctors to the African nation, where they assisted with post-war development for 14 months.[xxxiv] Castro’s political strategy proved successful, as Algeria’s first president, Ahmed Ben Bella, visited the island in 1962 as a gesture of gratitude.[xxxv] Thus, Castro’s development model legitimized his leadership in many parts of the world, rendering him a global player in the Cold War.
Although the Cold War drove much of Cuba’s policy towards medical diplomacy, the end of the era did not signify the retirement of Cuba’s international efforts. The government has openly promoted its projects abroad when given an international stage. For example, Minister of Foreign Affairs Bruno Rodriguez Parrilla’s presentation at the United Nations in 2014 demonstrates the Cuban government’s strategic rhetoric: “Cuba decided to maintain its medical cooperation in all the 32 African countries [affected by Ebola] where more than 4,000 Cuban specialists are working […] Our medical and paramedical staff will do it on a voluntary basis.”[xxxvi] Parrilla’s speech began by scolding the U.S. for its involvement in a series of international disputes and then concluded with a summary of Cuba’s fight against Ebola in Africa; the nation demanded that the West contribute to similar health efforts abroad.[xxxvii] Working with the World Health Organization, Cuba dispatched a flux of medical supplies and additional doctors to West Africa. Cuba’s response was impressive when considering that the total population of the island was only 11 million in 2014.[xxxviii] Soon after, Castro boasted of Cuba’s efforts, emerging from his retirement to remind Cubans of the relevancy of the Revolution: “Our country did not hesitate one minute in responding to the request [for support.] The medical professionals who travel […] provide the greatest example of solidarity a human being can offer.”[xxxix] Although Castro’s political strategy might have appeared hypocritical given his promotion of altruism, it proved effective nonetheless: “The U.N. General Assembly on [October 28, 2014] voted overwhelmingly for the 23rd time to condemn the decades-long U.S. economic embargo […] with many nations praising the island state for its response in fighting the deadly Ebola virus.”[xl] Thus, Castro used health care as a means of leverage within the international community, reshaping the discourse surrounding contemporary development.
Since the rise of former Venezuelan leader Hugo Chavez, Cuba’s economic survival has depended on its greatest export. The island’s economy experienced a massive shock following the collapse of the Soviet Union. Cuba had to rely on the communist nation for oil and practically all of its other resources; ironically, Cuba failed to fully develop its agricultural and industrial systems, primarily focusing on health care. Thus, Castro searched for trading partners who could support the country’s needs in exchange for Cuban medical services. After taking office in 1998, Chavez and Castro found that they had a double coincidence of wants.[xli] Chavez built his political platform on alleviating the country’s largest social problem: impoverishment. National interest, therefore, founded the beginnings of the countries’ close relationship: “[In 2000,] Mr. Chávez signed the first oil deal [known as the Convenio Integral de Cooperación] with Castro, providing Cuba with 53,000 barrels per day at cut-rate oil prices, a sum that [rose] to 110,000 barrels [in 2013].”[xlii] A nation with a seemingly endless supply of oil, Venezuela could effortlessly support Cuba’s demand. In exchange, Castro traded human capital, aiding development throughout Venezuela: “[As of 2013,] Cuba [had] sent some 40,000 doctors, dentists (find Emergency Dental services) […] and other experts in [the field].”[xliii] Further establishing Cuban medical diplomacy, the two nations signed the Cuba-Venezuela Cooperation Agreement on Health in 2000.[xliv] As a result, many Venezuelans traveled to Cuba to receive free medical care: “Over 100 health flights took place during the first three years of the program.”[xlv] Furthermore, since the policy’s establishment, Cuba has set up clinics in Venezuela, offering a variety of free, specialized medical services: “[Thirteen] modern eye clinics built in Venezuela were performing thousands of operations.”[xlvi] Despite Cuba’s promotion of goodwill, its diplomacy and distribution of services in Venezuela have ironically strained the island in recent years.[xlvii] As a large percentage of Cuban doctors have left the island to work in Venezuela, Cubans have complained that there are not enough medical resources to service domestic needs: “[The system] is neither fast nor efficient for two important reasons […] financial resources [and] the export of doctors, nurses and dentists in exchange for hard currency […] Ironically, many medicines that cannot be found at a pharmacy are easily bought on the black market.”[xlviii] Cuba, therefore, exposed a weakness of its new paradigm for development.
Despite the strain on its domestic health care system, Cuba continues to serve as an innovator of international development. The principal weakness of its model does not render the paradigm irrelevant. Rather, it is representative of the realities of the implemented development theory. Still, the far-reaching power of Cuba’s political tool has been demonstrated within recent months, as the Trump administration has sought to eliminate the Affordable Care Act. Many U.S. citizens have considered receiving medical treatment in Cuba if domestic health care costs rise. Cuba’s current leader, Raúl Castro, cannot allow the ideals of the Revolution to stagnate Cuba’s social progress, given the changing political tide. Thus, Cuba must consider its health care model as an evolving tool towards a sustainable future.
By Haley Wiebel, Research Associate at the Council on Hemispheric Affairs
Additional editorial support provided by Mariana Sánchez Ramírez and Tobias Fontecilla, Research Associates at the Council on Hemispheric Affairs
Feature image: Combined Joint Task Force Taken From: Combined Joint Task Force Horn of Africa
[i] “Fidel Castro “Biography,” last modified 2015, http://www.biography.com/people/ castro-fidel- 9241487#early-life.
[iv] Fidel Castro, “History Will Absolve Me,” 1953, https://www.marxists.org/history/ cuba/archive/castro/1953/10/16.htm.
[v] Daniel Trotta, “Two Cubans Lose Bids to Become First Opponents Elected to Office,” Reuters, last modified 2015, http://www.reuters.com/article/2015/04/20/us-cuba-election-opponents-idUSKBN0NA16F20150420.
[vi] Julie Feinsilver, “Fifty Years of Cuba’s Medical Diplomacy: From Idealism to Pragmatism,” Cuban Studies (2010) 86.
[vii] Constitution of the Republic of Cuba, 1976, art. 50, sec. 7.
[ix] Steve Brouwer, Revolutionary Doctors: How Cuba and Venezuela are Changing the World’s Conception of Health Care (New York: NYU Press, 2011), 56.
[x] Julie Feinsilver, “Cuba as a ‘World Medical Power’: The Politics of Symbolism” The Latin American Research Review (1989), 16.
[xi] Steve Brouwer, Revolutionary Doctors: How Cuba and Venezuela are Changing the World’s Conception of Health Care (New York: NYU Press, 2011), 22.
[xii] Ibid, 21.
[xiv] Steve Brouwer, Revolutionary Doctors: How Cuba and Venezuela are Changing the World’s Conception of Health Care (New York: NYU Press, 2011), 45.
[xv] Ibid., 57.
[xviii] C. William Keck and Gail Reed, “The Curious Case of Cuba” American Journal of Public Health (2012), 14.
[xx] The World Health Organization, “Cuba’s Primary Health Revolution: 30 Years On” Bulletin of the World Health Organization (2008): 327, http://www.who .int/bulletin/vol umes/86 /5/08-030508/en/.
[xxi] William Keck and Gail Reed,“The Curious Case of Cuba,” American Journal of Public Health (2012), 14.
[xxiii] Julie Feinsilver, “Cuba as a ‘World Medical Power’: The Politics of Symbolism,” The Latin American Research Review (1989), 10.
[xxiv] Ibid., 5-6.
[xxvi] Andrew Glass, “Fidel Castro Visits the U.S., April, 15, 1959,” Politico, last modified 2013, http://www.politico.com/story/2013/04/this-day-in-politics-april-15-1959-90037.html.
[xxvii] Danielle Renwick, “US-Cuba Relations,” Council on Foreign Relations, last modified 2015, http://www.cfr.org/cuba/us-cuba-relations/p11113.
[xxviii] Julie Feinsilver, “Fifty Years of Cuba’s Medical Diplomacy: From Idealism to Pragmatism,” Cuban Studies (2010), 87.
[xxix] John Kirk and Michael Erisman, Cuban Medical Internationalism: Orgins, Evolution, and Goals (Palgrave Macmillan, 2009), ebook edition.
[xxx] Steve Brouwer, Revolutionary Doctors: How Cuba and Venezuela are Changing the World’s Conception of Health Care (New York: NYU Press, 2011), 45-47.
[xxxi] John Kirk, “Cuba’s Medical Internationalism: Development and Rationale,” Bulletin of Latin American Research (2009), 499.
[xxxiv] Nancy Burke, Health Travels: Cuban Health(care) On and Off the Island (San Francisco: University of Southern California Press, 2013), 107.
[xxxv] John Kirk, “Cuba’s Medical Internationalism: Development and Rationale,” Bulletin of Latin American Research (2009), 499.
[xxxvi] Bruno Rodriguez Parrilla, “We Live in a Globalized World which Moves toward Multi-Polarity,” 2014, http://en.granma.cu/mundo/2014-09-29/we-live-in-a-globalized-world-which-moves-toward-multi-polarity.
[xxxviii] Seumas Milne, “Cuba’s Extraordinary Global Medical Record Shames US Blockage,” The Guardian, last modified 2014, http://www.theguardian.com /commentisfree/2014/dec /03/cuba -global-medical-record-shames-us-blockade-ebola.
[xl] Mirjam Donath and Lous Charbonneau, “For 23rd time, U.N. Nations Urge End to U.S. Embargo on Cuba,” Reuters, last modified 2014, http://www.reuters.com/article/ 2014/ 10/28/us-cuba-un-idUSKBN0IH1RN20141028.
[xli] José de Córdoba, “The Future of ‘Cubazuela,” Wall Street Journal, last modified 2013, http://www.wsj.com/articles/ SB10001424127887323884304578328252463429328.
[xliv] Max Azicri, “The Castro-Chávez Alliance,” Latin American Perspectives (2009), 100.
[xlv] Ibid., 101.