Most students and scholars of Cuba, even ideological enemies of the socialist Revolution, recognise the government's outstanding achievements in the provision of universal free health care since 1959. If not derived from study, this knowledge likely comes from first-hand experience on the island. This book, however, will leave even the knowledgeable reader astonished by the Cuban record: 124,000 health professionals have worked in 103 countries since 1963, and tens of thousands of poor foreign students have received free medical training in Cuba. In addition to compiling breathtaking statistics, Kirk and Erisman provide an historical narrative to the emergence and evolution of Cuba's medical internationalism, answering cynics and explaining the ‘how’ and ‘why’ of this extraordinary achievement.
Before 1959, private medical care in Havana ‘was among the best in the Americas’ (p. 27), but access was restricted by cost and location. Commitment to free universal healthcare on the part of the revolutionary government served to close class, race and urban/rural gaps in access. New doctors were trained to be motivated by patient needs, not profit. The book traces the evolution of the Cuban public health system, including the introduction of polyclinics in 1962 and family doctors in 1984. Today there are 32,000 family physicians in Cuba, and the patient–doctor ratio is 170:1, down from 900:1 in 1959. The principles of the Cuban approach are that ‘doctors are socialized and are taught to see themselves as revolutionaries’ (p. 31), that there is a ‘need for health care to be participatory … [and a] belief in cooperation over competition’ (p. 35), and that ‘emphasis [should be] placed on preventative medicine’ (p. 37). The authors discuss the socio-economic and welfare impact of the collapse of the Soviet bloc in 1990. Despite the material shortages, instead of budget cuts, social expenditures increased between 1990 and 2000, as did Cuba's medical cooperation abroad (p. 47).
Kirk and Erisman provide evidence to counter the cynicism of critics who denigrate Cuba's medical internationalism as a mere strategy to increase the sale of pharmaceutical products, raise export earnings or win political influence (as a stooge of the Soviet Union before 1990). Recognising the diplomatic, political and financial gains made by Cuba, the authors insist that ‘Cuban medical internationalism is not solely used to score political points abroad’ (p. 181, my emphasis). They label the global influence derived through Cuba's medical diplomacy ‘soft power’, an idea taken from Joseph Nye to describe countries which use the attractiveness of their culture, political values and foreign policies, rather than coercion or payment, to influence others. Acknowledging the re-establishment of diplomatic relations with countries receiving Cuban medical brigades and Cuba's influence in the international arena (Cuba was the first country to be elected twice to the presidency of the Non-Aligned Movement), they argue convincingly that while these successes may be outcomes of Cuba's medical assistance, they are not the motivation behind it.
Understanding this motivation requires a different type of theoretical framework: anti-imperialism, expressed as ‘proletarian internationalism’, socialist principles, and belief in the inalienable right to heath care, endorsed in Article 50 of the Cuban Constitution. These principles combined explain Cuban medical internationalism: in the authors' words, ‘proletarian internationalism has represented the moral tenet while medical (and related developmental) aid programs have served as policy vehicles through which it has been concretely operationalized’ (p. 90).
Cuban medical care for the victims of the Chernobyl (Ukraine) nuclear plant accident provides evidence of its ethical motivations. In March 1990, as the Soviet Union disintegrated and Cuba plunged into economic crisis, severely ill children from Chernobyl went to Cuba for medical treatment at no cost to their families or their government. Despite the end of fraternal relations and of significant economic ties, by 2009 23,000 people affected by the toxic fallout had been treated in Cuba, 80 per cent of them children. Cuba has footed the $300 million bill. Other extraordinary examples detailed are the Latin American Medical School, founded in 1999 and currently training 10,000 foreign students, and Operation Miracle, through which 1.5 million people in the region have had their eyesight restored since 2004.
The organisation of the book leads to some repetition, but some facts are worth repeating. Firstly, Cuban medical internationalism is not a recent policy initiative. Cuban medics went to Chile following a devastating earthquake in 1960, and by 1979 over 14,000 Cuban developmental aid personnel were working in 21 countries. Cuban medics accompanied military personnel to Algeria in 1963 and to the Congo in 1965 where, while Che Guevara trained insurgents, Cuban medics undertook the first ever mass vaccination programme in Africa. Secondly, the book emphasises the importance of South–South cooperation in Cuban foreign policy. Thirdly, Cuban medical assistance is not dependent on the political affiliation of governments. Fourthly, Cuban links with the Anglophone Caribbean are important.
Cuba's trade and cooperation agreements with Venezuela, and the establishment between the two countries of the Alianza Bolivariana para los Pueblos de Nuestra América (Bolivarian Alliance for the Americas, ALBA), have significantly increased Cuba's medical presence in Latin America and the Caribbean, a process detailed by the authors. Working in the most deprived areas, Cuban medics have achieved dramatic results in short intervals. For example, ‘in the first 18 months of Cuba's work in Honduras, there was a significant drop in infant mortality, which fell from 80.3 per 1,000 live births to 30.9’ (p. 129). In Haiti, between 1998 and 2004, infant and child mortality (up to the age of five) fell from 159 to 39 per 1,000 live births in areas served by Cuban doctors (p. 131). By 2004 Cuban medical brigades were providing health care to 75 per cent of Haiti's population and 247 Haitian students were attending a medical school set up there by Cuban professors, and by the following year 600 Haitians were studying medicine in Cuba.
This book was published before the January 2010 earthquake in Haiti which claimed 230,000 lives. Cuba has since offered to reconstruct Haiti's health care system, with support from ALBA and Brazil, to be staffed by Cubans and Cuban-trained medical personnel. The book also predates the June 2009 coup in Honduras, which reduced welfare-based cooperation with the country. Fortunately, the authors continue to research and publish on the impact of Cuban medical internationalism, while all proceeds from this book go to MEDICC, an NGO which promotes cooperation among the US, Cuban and global health communities.
