Episode #10: Andrés Pertierra on Cuba’s Medical Missions
Andrés Pertierra, a historian of Latin America and creator of Orígines: A Cuban History Podcast, discusses the humanitarian, political and financial motives behind Cuba’s overseas medical missions.
A former student at the University of Havana currently studying for his PhD at the University of Wisconsin-Madison, Andrés also shares insights into the Cuban health system, the recent history of US-Cuba relations, and why the revival of US sanctions are unlikely to bring about democracy on the island.
This interview, which took place on April 21st 2020, has been lightly edited for length and clarity. The full episode is available here.
Laurence Blair: Cuban doctors have been among the first responders to the coronavirus pandemic worldwide. In March alone, Cuba had its medical personnel in 16 different countries. The backdrop to all of this is Cuba’s famous — to some notorious — medical programme which saw about 37,000 doctors deployed in 77 countries around the world in 2015, with some returning since then. Where do these medical brigades come from and why is Cuba exporting doctors around the world?
Andrés Pertierra: The medical brigade programmes are actually really old. More recently a lot of people associated it with Cuba’s relationship with Venezuela since 1998. Since very famously, the “doctors for oil programme” was really fundamental: not just a major programme in terms of the number of medical personnel sent, but also a major factor in Cuba’s economic recovery from the worst of the Special Period of the 1990s, when Cuba’s economy virtually collapses due to the disappearance of its trade with the Soviet Union and the Eastern Bloc.
But actually, the programme dates to in some in some form to the 1960s. It had a relationship with newly independent Algeria and was sending medical personnel there and Algeria was sending oil back. Though of course it’s increased in scope and its economic importance for Cuba in recent decades. In 2016, Cuba got about US$6.3 billion, with a B, in revenue, which is about approximately 6% of its GDP, from these doctors abroad. So it’s a kind of a marriage of both pragmatic, economic necessity for the government and a nice little mix with its own ideology. I guess something analogous for many of our listeners would be the Peace Corps — it jives with the ideology of the government and it’s good diplomacy, but at the same time, it does serve a more practical purpose.
It’s increased in importance as a source of revenue, especially since the sugar industry was largely dismantled in the 2000s, and it’s taken on a new dimension. This also creates new incentives to really pressure doctors to go abroad, even if they don’t necessarily want to, because this is a huge commitment, it’s several years, travel home is sporadic. You can’t bring your family, which is really huge — if you have young children, imagine missing a couple of years of their lives. So the programme is old, but there’s been a quantitative and qualitative change in its in its function over the past 20, 30 years.
LB: When you were studying at the University of Havana and rubbing shoulders with future doctors who were due to be posted abroad, what were they saying about it? Were they happy, or saying “this is a bad deal — two thirds of my income is going to stay with the government, I’m going to miss my girlfriend or kids for a couple of years”…?
AP: When I went, doctor salaries were about half of what they are now. Now I think that they’re earning closer to US$50 to US$60 a month. Which is abysmal, but it’s something closer to a very basic minimum wage to survive in Cuba. So it was almost a symbolic wage, and while they don’t get paid a lot when they’re abroad, it was still significantly more than they were being paid at home.
The doctors I met wouldn’t always be happy, but they’d be like, “hey, I can save up during my time abroad, I can live on half of what they’re giving me and just be really really tight-fisted. I can bring that home and invest in this and that and maybe I can save up enough to buy a car and then live off of my car, do informal taxi work to make ends meet.” So it was a mixed bag.
LB: I suppose defenders of the scheme will also say that if you’re a Cuban medical student you get your degree paid for by the state. I’m not sure how transferable that is, at least outside of the global south, but that gives you some possibilities assuming you can leave the island.
AP: Becoming a doctor in Cuba is a bit different to in the west. You’re closer to a civil servant going to different postings then you are a freelance doctor. You’re giving a basic service the same as a policeman or something similar. So Cuban doctors go into the degree knowing that a good portion of their careers will be dependent on working within the bureaucracy, trying to find a good posting, that kind of thing. So there’s a different mentality to it.
You do get the degree for free, but all degrees are free in Cuba. But even then you have to do something called Servicio Social, social service. I believe that Germany has something vaguely similar. For two years after the degree — or only one year if you’re a man and had already did military service — you work for a pretty low wage at some job related theoretically related to your discipline, basically a crap job that no one else wants, but society would benefit from.
There’s an annual student march — la marcha de las antorchas — which commemorates the shooting of Cuban medical students in the nineteenth century who were falsely accused of desecrating the tombs of Spanish officials. Our professor assigned us to go down and see which disciplines were represented, because it’s voluntary to go to the march. Humanities and history weren’t all that well represented, but doctors and scientists were. I mean, it makes sense, but medical students did tend to be a more as a rule ideologically committed than people going into letters and the humanities.
LB: To rewind a bit to the origins of the medical missions in the 1960s, why is it doctors in particular that are sent abroad — not agronomists, engineers, architects? Is it an inheritance from before the revolution, or a sort of Third Worldism, the idea that here is a very tangible way we can help people?
AP: I’m not sure how much of it is about what preceded 1959, because many older Cuban doctors, just like most professionals, left the country after the revolution. My family included, my grandfather was an accountant. So Cuba definitely had a shortage. They didn’t really have a lot of doctors to begin with in terms of treating the needs of the rural population. Many of them had worms in their feet because many kids didn’t have shoes. But I think doctors are very symbolically powerful in a way that an agronomist isn’t necessarily. If a Cuban doctor saves your daughter’s life or helps you to see, these are the kinds of things that stick much more in people’s minds.
Another part of it is that after 1959, Cuba invests a massive amount of capital over decades in training people, so there has been historically a surplus of trained professionals in all kinds of disciplines. The Cuban government has trouble monetising it, it’s not an investment that necessarily pays off. So if you have surplus of doctors, countries abroad need doctors, you gain diplomatically and symbolically, but you also gain money. I mean, Cuba does and has historically sent other kinds of experts abroad.
LB: Of course — Cuba has often sent soldiers and spies overseas for one. I also wonder if the presence of Che Guevara in those early years in the Sierra Maestra, where medical care is part of the package the revolutionaries are offering — he would prescribe whatever he had in his medicine bag — sort of enters the DNA of the revolution.
AP: It’s also very much the philosophy of se da lo que se tiene y no lo que se sobra, which is, you give what you have and not what you have extra of. So in a way, even the fact that there was scarcity of doctors early in the revolution, and they were still willing to send doctors abroad, gave an even more symbolic weight. It really solidifies Cuba’s bona fides as a third world country believing in international Third World solidarity.
It also makes sense as part of Cuba’s political project in the 1960s, 1970s, to get to get on top of the non- aligned movement. Because you had all these third world countries, especially decolonising nations in Africa and Asia, that were trying to create a stance where they didn’t have to become either a satellite of the USSR or the US. And if Cuba sending doctors abroad, it solidifies Cuba’s efforts to lead that. Cuba wasn’t a satellite, it had a lot more room to manoeuvre than many dependencies, but it was a dependency of the USSR, which undermined its ability to lead a non-aligned movement. But I think that that’s also part of it.
LB: Has sending its doctors abroad impacted Cuba’s ability to respond to the coronavirus pandemic? What’s the situation on the island right now and how ready is Cuba to respond?
AP: As of April 19th, Cuba has done 28,598 tests and only 1087 have come back positive. There were 52 new cases on April 19. Just to give you an idea of like, how many new cases are coming in on a daily basis at this point and 36 dead total. So it’s not great, but I mean, it’s still, it’s still largely contained. They’ve closed their borders, there is no internal traffic, and as a rule, you cannot go there as a tourist or for academic reasons right now. They are encouraging people to isolate at home. The school system is shut down. They really resisted closing the borders for a while because they depend on tourism as a key part of their economy. And to import most of their food they need that foreign currency. They are even isolating provinces from each other. So for example, Granma province in eastern Cuba, one of the bread baskets, and is being isolated from more infected provinces.
They also benefit from being an island, and the Cuban government does have the benefit of doctors being basically civil servants. So they’re able to mobilise the doctors as if it was an army. Cubans are also fairly conscientious about health issues. Infectious diseases have been a chronic problem in the island, going back to at least the colonial period. During the independence wars, the independence fighters liked to say that their greatest generals were June, July and August, because that’s when the most Spaniards would die of infectious diseases. You had occasional outbreaks of dengue, of cholera, and they end to impose very strict measures to contain it, which historically have been fairly successful.
Has having the doctors abroad hampered the the Cuban government’s response? I don’t think it has, especially since — as troubling as the 36 deaths and the 1087 cases are so far — it seems like they contained it in time. A bunch of doctors have come back from Ecuador, Brazil, Bolivia and El Salvador in the last two years, as the US has put pressure [on regional governments to cut] the programme because it’s a source of revenue.
On the doctors who have been sent to places like Italy, I would like to note that it’s still not entirely clear to me what the conditions are. Because these aren’t traditional historic doctors for oil programmes as in Venezuela — heavily subsidised oil in exchange for medical personnel and some money to pay for their salaries. It’s not clear whether there has been even a more formal economic deal, because they’ve largely won over most of the EU in terms of international political relations. Spanish capitalists have major investments in Cuba, especially the hotel industry. So Spain is very much on board with Cuba being able to normalise economic relations with the rest of the world. But it’s not clear to me if Cuba’s going for a lot of money, or whether the hope is this will pay political and diplomatic dividends in the long run.
LB: Perhaps it reflects a desire to drive a wedge between the EU and the US in terms of sanctions on the island. On the point of preparedness, am I right in saying that Cuba performs better in terms of child mortality rates than the United States?
AP: Cuba does have tend to have better stats on on child mortality than the US though there’s definitely a lot of criticism of those statistics, and they should be taken with a grain of salt, like all government statistics. But I don’t think it is an exaggeration to say that they way outperform the low infant mortality that is expected for third world country. Just to give like an a snapshot of how it works on a day to day basis, two years ago, a friend of mine and his wife were having a baby and had the local medical clinic for pregnant women at walking distance from their house. They go lots of medical and pre-natal advice, emergency care, and prescriptions for free, zero dollars. So the the kind of small, easily preventable mistakes that new parents especially might make tend to be avoided because they have regular access to doctors.
LB: I suppose the major criticism is that it’s all very well to provide these kind of services, but if you’re a regime not providing basic freedoms then that trade-off doesn’t make sense. Zooming out to where Cuba was headed before this pandemic, Trump has rolled back the Obama administration’s thaw with Cuba and restored sanctions. Does this tougher line from Washington make democratic openings less likely?
AP: Historically, domestic opening up has been tied to US foreign policy. Cuba justifies the restriction of many freedoms by the fact that the country is besieged in the economic embargo, the fact that the US spends millions a year on literal propaganda networks like TV and Radio Martí — which last I heard we’re getting in trouble because they were posting anti-Semitic George Soros conspiracy theories. So there is a massive apparatus and a lot of money being invested in trying to overthrow the Cuban government. So behind closed doors that’s basically the idea: Cuba survived where Allende didn’t, Cuba survived where all these other Latin American governments that stood up to the US got overthrown in military coups , but the Cuban system, criticise it all you want, survived. That is their argument.
LB: I guess its leaders saw what happened to Jacobo Árbenz in Guatemala and got the sense that democratic socialism in the Americas gets crushed, or indeed anywhere around the world.
AP: Che Guevara was in Guatemala in ’54 during the coup. So we can we can definitely bet that it was a formative moment for him. I was reading “Allende’s Chile” by Professor Tanya Harmer: in the early 1970s Fidel Castro was telling Allende to actually slow his roll on opening up to more radical reforms because, he says, you’re going to get the the Americans pissed off and they’re going to overthrow you. Allende didn’t really listen to him, but just just a bit of an irony right there.
In terms of repression, it’s definitely not as bad as it used to be in the 90s. The nadir was the 1960s with the labour camps, the Unidades Militares de Ayuda a la Producción, which lasted from ‘65 to ’68. In culture, the nadir was the quinquenio gris, the grey five-year period between 1971 and 1976. It still has a wax and a wane to it: after George Bush started to move against Cuba in many ways the Castro government responded in 2003 by rounding up 75 dissidents, something the opposition called the Primavera Negra, the Black Spring.
In 1961, Cuba and the US break relations. In the mid-70s, Cuba and the US almost come to an understanding. Henry Kissinger, Secretary of State under President Gerald Ford, tries some kind of normalisation but that gets stymied because Cuba just intervened in Angola. Jimmy Carter quasi-reestablishes diplomatic relations in the late 1970s through the establishment of “interest sections” which are de facto embassies. But that was the extent of US-Cuba relations, until Obama reset formally re establish diplomatic relations in 2015. He might have actually gone further in terms of normalisation, but thanks to the Helms Burton act of 1996, which Bill Clinton signed, the ending of the embargo is actually no longer the prerogative of the executive but now requires an act of Congress.
American tourism also just explodes in the late Obama years. You also have Cuba then importing a good amount of food from actually Republican controlled agro-export states in the West, as part of this actual political strategy to try and push the needle on normalisation. Because the the real support for the embargo against Cuba is especially hard among in Florida because it’s a swing state, and its Cuban Americans. But a lot of agro-export Republicans want Cuba to buy their pigs and their cows and their ideology is not red, or not not red, it’s green. So they have that relationship. It’s just that the Cuban Americans in Congress and the importance of Florida have kind of prevented that.
Then with Trump, you basically have as far as the dismantling of the thaw as you could get, though he does stop short of completely reversing Obama in interesting ways. He removes most of the US diplomatic personnel from Cuba, because of the so-called Sonic Attacks. The short version is that it does not actually appear to be sonic or radiological attacks, it might be entirely psychosomatic attacks.
LB: This is the case of US and Canadian diplomats who reported hearing buzzing or really loud noises overnight — and the investigation into finding out whether they were being bugged or some kind of device had been put in their rooms.
AP: The first attack supposedly began in late 2016 when Obama was president. It came to light in the summer of 2017 when Trump was in his first year of office, the Canadians came out saying that they were withdrawing their personnel. The idea that the West would lie about these attacks makes perfect sense to me, it wouldn’t surprise me. But the Canadians have historically had close economic and political ties to Cuba. There’s a lot of Canadian tourism that goes to Cuba, trade, all the rest. So they have really no incentive to fabricate these attacks, especially under the Trudeau government. Last I heard they still haven’t come out with any kind of confirmation that they’re psychosomatic. So I don’t think anyone really knows what happened there, we may never know.
But the long story short is the US uses that as a basis to withdraw all the skeleton crew from their embassy in and their consulate in Havana. So Cubans who want to come to the US for any reason, family reunification, academic trips, now need to go to establish third countries like like Guyana or Mexico for example. So if you want a visa to come to the US, you have to first pay for a trip to this third country, get a visa for that third country, stay there. As someone who’s actually worked as a legal assistant and doing immigration law for a while, consular processing can at least two weeks, perhaps as long as three, and that’s without something going wrong. So if you’re Cuban working on Cuban salary, how are you going to live in Mexico for basically a month?
On top of that, you also have the US really aggressively going after Cuba’s medical programmes abroad in public. Mike Pompeo was publicly tweeting that countries should shut down these programmes earlier this year. And privately we don’t know what is being offered. We know that in the past two years. Ecuador, Brazil, Bolivia and El Salvador have all shut down their programmes. The Brazilian programme actually led to 9000 Cuban doctors returning to Cuba.
LB: We’re talking about doctors working in rural, Amazonian communities, places where the average Brazilian doctor probably doesn’t want to go. And I understand that some Brazilian states are now in talks to get those doctors back?
AP: Although I think they’re not asking for new doctors from Cuba but rather to rehire the doctors that stayed, because about 1000 to 2000 doctors didn’t come back. And they were promised that they would get rehired if they stayed — they were told, “there’s no longer this tyranny that represses you, we will pay you your full wage” — and then it emerged that they were not being allowed to practice and being forced to jump through hoops to get their medical degrees re-validated even though they’d been practicing in Brazil for months or years.
There have also been other sanctions, the US has really been going after Cuba’s relationship with Venezuela, which provides a large amount of Cuba’s oil, which it uses not just for its own energy use, it refines it and re-exports it for cash. They have activated Title III of the Helms-Burton Act which lets those affected by the nationalisations of the early revolutionary period and their heirs sue Cuba and sue countries and companies that trade with Cuba for supposedly trading in stolen goods. For example, the heirs of the owners of the port where a lot of cruise ships dock in Havana are suing, also the heirs of (infamous mobster) Meyer Lansky are suing Cuba over properties he owned. I think this was a mistake for a lot of folks because everyone back then was very dirty, everyone was mobbed up, so I’m not really sure they want to dig into who owned what and why in the 1950s.
LB: Does this ramped-up pressure from the Trump administration increase the prospect of greater freedoms on the island?
AP: Historically it hasn’t. That has been the lesson of the embargo. It’s part of why the Obama administration did not support the embargo. No-one who really studies Cuba thinks the embargo is, regardless of being moral, effective.
What it has done is reaped an enormous amount of suffering and pain on everyday Cubans, and the key people in the Cuban government supposedly being targeted have been left entirely intact. The point of the embargo and all of these sanctions is to make life so absolutely miserable for everyday people that they revolt. But if they don’t revolt then not only is it a cynical policy and an amoral policy, it’s an unproductive policy. And what it does is make people rally around, it justifies the Cuban government’s restrictions of freedoms and its defensiveness.
Will it end up being effective this time? I don’t know. There are some people who like to say that it didn’t work in the 1990s, when things were much worse than now — people went blind from vitamin deficiencies. That only resulted in one popular protest, which was the Maleconazo in 1994, and then that was dismantled when a countermarch was staged by Fidel Castro and his supporters, who talked the protesters off the ledge. People cite that precedent and say nothing is going to happen this time.
But I do think that circumstances are different. It’s a different generation; Miguel Díaz-Canel is not Fidel Castro, he did not fight in the Sierra Maestra or overthrow Batista, he does not have the legitimacy that Fidel Castro had. He’s a new guy, so he can’t command the general populace, the bureaucracy or the military with the same authority. It’s not clear to me Díaz-Canel could play things the same way if things were to go wrong. And young people, especially now things have got better since the 1990s, and even old people, they’re tired, they just want to live their lives, have kids, and they’re not as ideologically committed as their forebears. So it’s not clear to me that if Cuba goes through a second Special Period the government will be able to get through it unscathed.