That Cuban doctors are being sent abroad by their government to help with the current COVID-19 health crisis is obviously a welcome thing. To those on the receiving end, it is undoubtedly a priceless, life-saving gift. For many people it is one more expression of the Cuban state’s progressive character. Yet, it is important to bring out lesser known aspects of this Cuban doctors abroad program, including the financial benefits obtained by the government, and the conditions under which its doctors labor on the island and abroad that expose the Cuban state’s undemocratic character and the impact that this has on the Cuban people.
According to the Cuban government, it charges its medical clients abroad on a sliding scale according to the economic possibilities of each country, and in certain cases it provides the medical services of its doctors free of charge. It is not that well known however, that the Cuban government’s export of those medical services is, in fact, the state’s biggest business and source of profit. In 2018, the Cuban state earned $6.2 billion from the export of medical services, constituting its largest source of foreign exchange (The Guardian, May 6, 2020), amounting to twice as much as its hard currency income from remittances from Cubans abroad, its second biggest earner, and also greater than tourism which is its third-ranking hard currency earner. The following year, in 2019, medical services accounted for 46 percent of Cuban exports and 6 percent of the island’s GDP.
Towards the end of 2018, Cuban medical operations abroad involved the export of 28, 000 doctors and other medical personnel to 67 countries, a reduction from the high point of 50,000 in 2015, before Cuban doctors were expelled from countries like Brazil, Bolivia, El Salvador and Ecuador as their respective governments turned to the right, and far right, as in the case of Jair Bolsonaro in Brazil.
Cuban doctors receive only about 25 percent of what foreign governments pay to the Cuban authorities for their services (most host countries also provide free housing to the Cuban doctors although of widely varying quality.) These doctors have no way of negotiating their share with the Cuban government since they have no right to organize independent unions to press for their demands. Unions in Cuba are state-controlled, and function as one of the principal transmission belts for the Cuban Communist Party’s policies and decisions. And doctors abroad are subject to a series of governmental rules limiting and attempting to prevent their mobility and desertion abroad, like for example having their compensation, or part of it, deposited by the state in Cuba itself, and having to leave their spouses and/or children behind on the island. Moreover, Cuban doctors must hand over their passports to their supervisors as soon as they arrive in the foreign country where they are going to practice. Desertion is heavily punished by barring the deserters from visiting Cuba for eight years, even though they are Cuban citizens.
Yet, Cuban doctors are more than willing to practice abroad under the sponsorship of their government. Aside from the humanitarian sentiments that may motivate them, the highly reduced 25 percent of the pay they receive for their services abroad is far better than what they would normally earn in Cuba. As Ernesto Londoño pointed out in a New York Times article on Sept. 29, 2017, about Cuban doctors in Brazil—by that time 18,000 Cuban doctors had already served in that country—the agreement of the Cuban and Brazilian authorities in 2013, allowed each Cuban doctor to receive, after their own government took its own very large slice, 2,900 reais a month, worth $1,400 in 2013 and $908 in 2017, a truly extraordinary amount when compared with, after the big salary increase in Cuba in March of 2014, 1,500 pesos, or $60 a month (at the prevailing exchange of approximately 25 Cuban national pesos or CUP to the dollar) that they would have earned at home (Havana Times, March 21, 2014). Besides making far more money than on the island, Cuban doctors in Brazil, as in many other countries they have worked, also gained access to a wide range of consumer goods unavailable at home, which they can take home when they return, an issue not mentioned by Londoño. This is another instance of people voluntarily submitting to exploitative conditions for lack of an alternative.
The Cuban government, and its defenders abroad, has often justified taking its 75 percent cut from their doctors’ work pay abroad by pointing out that this was a fair way to reimburse the state for the public expenses incurred in educating these doctors for free. In fact, however, by the government’s own reckoning, Cuban doctors are considered to have “paid back” their free education upon having completed their “social service”—contributing, immediately upon graduation, their newly acquired skills for a two year-long period, (three years for males when combined with their military service) on a full time basis, wherever the government assigns them. (A similar one year-long program has existed in Mexico, where medical education is free, for more than eighty years.) It is only after having completed their social service that doctors are free to apply to fill vacancies in their desired localities and/or according to what they consider, in relative terms, the most favorable working conditions. Yet, from the time they do their social service, they are considered state employees (private practice is illegal) and are subject to the orders and conditions unilaterally dictated by the Cuban state. That is why this system should be described as statist medicine as against socialized medicine. The latter would allow, in a democratic and socialist system, for doctors to choose to work either for non-state social organizations—like independent unions, neighborhood associations, workers councils, municipal governments-—or for the state, as part of a universal, fully comprehensive service totally financed from the public purse.
Not surprisingly, many Cuban doctors opt to desert once they are serving abroad, in spite of the difficulties and obstacles involved. Organizing independent unions to challenge Cuba’s one-party system is very risky; most people on the island —doctors included—probably don’t even consider it or believe it is a real option. Many of them deserted and obtained asylum in the United States under the Cuban Medical Professional Parole Program established by George W. Bush in 2006.This program allowed Cuban doctors stationed in other countries to obtain permanent residency in the United States and facilitated their legal practice after they had arrived in this country. By the time the program was abolished by Obama at the end of his presidency in January 2017, some 7,000 Cuban doctors had taken advantage of it. It goes without saying that—as it has been the case with the criminal U.S. economic blockade of Cuba established in 1960—the program was not created to promote the welfare of the Cuban people or to reestablish “democracy” in the island, but to attack the Cuban economy, in this case through the exacerbation of the island’s “brain drain,” in order to punish a regime that does not obey Washington’s rules of the game.
It is also worth noting that even though Trump has eliminated many of Obama’s measures to soften the blockade, he has done nothing to reestablish Bush’s medical program, evidence that his anti-immigrant sentiments and policies are stronger than his anti-Communism. Absent the escape provided by the U.S. sponsored Cuban Medical Professional Parole Program, at least 150 Cuban doctors in Brazil filed lawsuits in that country before Bolsonaro came into office, challenging the Cuba-Brazil agreement, and demanding to be treated as independent contractors entitled to earn full salaries, and not as employees of the Cuban state. The lawsuits became moot after Bolsonaro came to power, and Cuba withdrew its medical personnel (approximately 8,000 people) from that country. As of June 2019, there were several hundred Cuban doctors originally brought to work in Brazil that refused to return to Cuba. They remained in Brazil in a state of limbo, working in any job they could find just to survive, since they are ineligible to practice there unless they pass an exam that has not been offered since 2017. Just recently, however, the Brazilian government hired and licensed 157 Cuban doctors to help with the Coronavirus crisis that has exploded in that country under the criminally negligent policies of Bolsonaro’s government (Al Jazeera, May 19, 2020).
Meanwhile, the people in Cuba have been paying their own share for the export of doctors. In a study of the Cuban economy between 2007 and 2017 (“Social Welfare and Structural Reform in Cuba, 2006-2017,” Cuba in Transition, vol. 27, 2017), the prominent Cuban economist Carmelo Mesa-Lago indicated that while on the one hand Cuba’s universal and free health system had achieved major improvements—such as a further decrease in infant mortality, the reduction of the number of inhabitants per dentist [which although important, is however only part of the serious problems of dental care in Cuba], and an increase in vaccinations resulting in the elimination or reduction of most communicable diseases—on the other hand, maternal mortality had increased, the number of polyclinics and hospitals had declined, including rural hospitals and rural/urban health centers which were shut down in 2001, with patients being then referred to regional hospitals, with the resulting increase in time and transportation costs, and higher risks in emergency cases. He also found that the number of available hospital beds had also shrunk and expensive diagnostic and testing procedures had been cut while physical plants and equipment had continued to deteriorate. Besides a severe shortage of medicines, Mesa-Lago reported, hospital patients had to provide their own supply of sheets, pillows, and similar items.
As they specifically relate to Cuba’s export of medical personnel abroad, Mesa-Lago’s findings indicated that while the number of doctors for the 2007-2017 period increased by 21 percent, setting a new record in 2016 with 90,161 new doctors, once the 40,000 doctors abroad in 2017 were subtracted from that number this significantly lowered the number of doctors working on the island to 224 inhabitants per doctor, almost to the level of 1993, the worst year of the economic crisis that followed the collapse of the Soviet bloc. The shrinkage was worse for specialists, a high proportion of which left to work abroad. (The author is personally familiar with the case of a woman friend whose colonoscopy was botched by a technician assigned to replace a specialist who had been sent abroad.) Mesa Lago added that the export of doctors has had a particular bad effect on the family doctor program, a very successful program created by the government in the 1980s, which was considerably reduced by 59 percent in the 2007-2017 period of his study. Compounding the serious problems affecting the Cuban health system caused by the falling number of doctors left inside Cuba was a 22 percent fall (not necessarily associated with the doctors’ export program) of other medical personnel—technicians and nurses—found by Mesa Lago in that same study.
Recently, Covid-19 hit Cuba as it did virtually the whole world. According to Granma, the official Communist Party newspaper, 1,963 people had been reported as having been infected (Granma, May 26) and 79 people had died (Granma, May 19). As of May 25, 434 patients were hospitalized (Granma, May 26) and 3281 were under observation in health centers (Granma, May 19), but quite surprisingly, only 434 a week later (Granma, May 26), while 1, 823 were being followed at home (Granma, May 26.) While the Cuban government took drastic measures to stop contagion such as closing the country to tourists and halting public transportation, it is too early to tell, since there has been very little independent information so far, on how Cuba’s health system has fared in overall terms in treating its COVID-19 patients and even the accuracy of the statistics reported above.
Many in the broad left attribute the serious problems affecting the Cuban health system, including those specifically resulting from the export of Cuban doctors, to the U.S. economic blockade. It is unquestionable that since its establishment in 1960, this blockade has been significantly impacting the Cuban economy. Although softened by Obama in his second term, most of his positive changes were then cancelled by Trump: limiting U.S. travel to the island, limiting remittances, and reaffirming the closure of the U.S. market to Cuban goods and the ban on U.S. investment in Cuba. This ban was in fact reinforced by Trump, who froze new foreign investment in Cuba when he enforced for the first time Title III of the 1996 Helms-Burton Act that forbids any economic dealings involving any land or installations that were confiscated from U.S. firms by the Cuban government in the early 1960s, and increased sanctions on international banks that do transactions with Cuba. Although the still intact U.S. Trade Sanctions and Export Enhancement Act of 2000 authorizes the sale of food and most medicines to Cuba, it imposes so many difficulties for the commercial transactions involved in the sale of those products to the island, such as demanding cash payments in advance (no bank credits accepted) and obtaining so many licenses that it subverts the purportedly liberalizing purpose of that Act.
It must be noted, however, that it is only the United States that has been boycotting Cuba, and that many other capitalist countries, especially Canada, Spain (including Franco’s Spain), and many countries in what became the European Union, have maintained economic relations with the island providing it with a wide range of economic opportunities since the very beginning of the blockade. Therefore, the US blockade explains Cuba’s problems only to a limited degree. Much more important has been the role of the undemocratic bureaucratic Cuban political economy ran by a one-party state.
In all its essentials, Cuba is a replica of the Soviet socio-economic and political model, where a bureaucratic class runs the economy without any institutional input or constraints by independent unions or any other popular organizations. It is only on the Internet to which only a minority in the island has access mostly because of its very high cost relative to existing wages, and which the government has not yet been able to totally control, that one can find many Cuban critical voices including those expressed in the nascent independent civil society associations that are completely shut out by the state controlled mass media (newspapers, television stations and radio). Thus, there is no transparency and open, public discussion of Cuba’s problems–whether political, social or economic—unless the regime chooses to publicize them for its own purposes, and as long as it controls them. Information about the economy is systematically distorted, and the transmission of the clear signals necessary for the proper functioning of the economy are continually blocked: authentic feedback, accurate information, and independent initiatives from below are systematically discouraged lest they might pry loose the control of the one-party state. In the absence of an open, democratic public life citizens lack the power to bring accountability to planners. The lack of an open press and any independent means for mass communication has facilitated system-wide cover-ups, corruption and inefficiency. The lack of democracy also promotes apathy and cynicism among working people who have no significant independent input, much less control over what happens in their workplace.
This inefficiency and corruption have been reflected in every sector of Cuba’s society, including the health sector. Ten years ago, Uruguayan Fernando Ravsberg, a critical journalist by no means hostile to the Cuban system, writing about hospitals in Cuba lamented the waste of expensive ophthalmology equipment left abandoned, unused, in various warehouses; of the waste of the new burn unit in the well known Calixto Garcia Hospital next to the University of Havana’s main campus, which had not been used for a single day since it had been inaugurated two years earlier. The facilities there were unusable anyway, noted Ravsberg: the roof had fallen on several occasions, and the very expensive bathtubs for burned people could not be used because of low water pressure. Similarly, the new state-of-the-art operating room in that hospital was unusable due to extensive leaks in the water pipes and a roof that leaked whenever it rained. The tiles there kept coming off the walls, due to the lack of sufficient cement, which had likely been stolen during construction, as had happened with the Almejeiras hospital, in Central Havana (“Los Recursos de Salud,” Cartas desde Cuba, April 29, 2010).
While conceding that the Cuban regime is undemocratic, even economically inefficient and “sometimes” repressive, many people on the left, besides, as they should, opposing U.S. intervention in Cuba, regard the Cuban regime as progressive and deserving of their support because of its focus on lifting the Cuban people out of poverty and its attempts to do so through its public education system all the way up to and including professional training, and a guaranteed system of health care. This position implies an arithmetic calculation of gains and losses where social welfare-gains more than compensate for the loss of democracy and political freedom. Yet, the welfare of a people is intrinsically connected to the presence or absence of democracy. What has happened with the health system is one example of that. The impact that the export of doctors has had in worsening the existing problems in that sector is a more specific one.
There is a loss that cannot be condoned when it comes to thinking about whether a particular regime should be politically supported: the loss of class, group (whether defined by race, gender or sexual orientation) and individual political autonomy, and the loss of freedom to organize independently to defend class and other group interests, along with the associated civil and political freedoms to make such organizational independence possible and viable.
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