Medical Internationalism in Cuba by JOHN M. KIRK “What is the secret of our approach? It lies in the fact that human capital can achieve far more than financial capital. Human capital implies not only knowledge but also-crucially important- political awarenes,. ethics, a sense of solidarity, truly human feelings, a spirit of sacrifice, heroism and the capacity to do a lot with very little” Fidel Castro Ruz, at the first graduation of ELAM students, August 2005 The often-repeated quotation, allegedly from Máximo Gómez that “los cubanos, o no llegan, o se pasan” certainly applies to the programme of Cuban medical internationalism.(1) Cuba certainly “se ha pasado” in terms of this policy: as of April 2012 there were 38,868 Cuban medical professionals working in 66 countries–of whom 15,407 were doctors (approximately 20% of Cuba’s 75,000 physicians).(2) In Africa some 3,000 Cuban medical personnel are currently working in 35 of the continent’s 54 countries, while in Venezuela alone there are approximately 30,000.(3) But that is only part of the story, since there are many other significant facets to Cuban medical internationalism. In all cases it can be argued that “human capital” is the most important common denominator. This article, based upon seven years of research and some 70 interviews with Cuban medical personnel, both in Cuba and abroad, seeks to provide a broad overview of the importance of Cuban medical internationalism. There are several, very different, programmes of medical cooperation that have been employed, and this article offers basic data on their evolution and impact, as well as providing some analysis of the rationale for their development. Medical internationalism is not a recent phenomenon, and in fact can be traced back to 1960–when Cuba’s first medical delegation flew to Chile following a major earthquake there. The assistance was significant because Cuba had strained diplomatic relations with the right-wing Alessandri government at that time, emphasizing clearly the humanitarian nature of the mission. A larger medical delegation was sent in 1963, when Cuban medical personnel helped to establish the public health system of Algeria, following its independence from France. Again, the historical context is worth noting, since approximately one half of Cuba’s 6,000 physicians had left the country, mainly heading for Miami. In addition France, under President Charles de Gaulle, was one of Cuba’s few remaining allies at that time—highlighting Cuba’s commitment to humanitarianism rather than political gain. The significance of the Cuban contribution at the time was well emphasized by the Cuban Minister of Health, Dr. José Ramón Machado Ventura: “Era como un mendigo ofreciendo ayuda, pero sabíamos que el pueblo argelino la necesitaba incluso más que nosotros, y que la merecía”.(4) Human capital, as defined by Fidel Castro, was even at this formative stage of the revolutionary process once again the fundamental basis for the decision to provide medical support. The record of medical collaboration has continued, particularly in developing and underdeveloped countries, and to date almost 135,000 health workers have participated in overseas missions. To put this in context, Cuba currently has more medical personnel working abroad on medical cooperation missions than all of the G-8 nations combined, an astonishing record. There are three basic stages in medical internationalism employed by Cuba–the early years of the revolutionary process (best typified by the sending of missions to Chile in 1960 and Algeria in 1963); the mid-1970s (when Cuba, supported by the former Soviet Union and socialist countries of Europe, developed a particularly strong programme of collaboration in sub-Saharan Africa); and finally the period beginning in 1990 after the nuclear meltdown in Chernobyl. This was followed by a major increase in medical cooperation in the late 1990s, especially in Latin America and the Caribbean, following the havoc caused by Hurricanes George in Haiti and Mitch in Central America. This most recent stage has resulted in numerous international health initiatives, ranging from integrated health programmes (used in dozens of Third World countries) and providing basic access to healthcare to millions of people who often had never received any attention to the extremely successful “Henry Reeve” Emergency Medicine Contingents which have been employed in natural disasters. While the record of medical internationalism is a long and honourable one, the vast majority of Cuba’s contributions have been since the late-1980s, the focus of this essay. One example is the support given to victims of the Chernobyl nuclear reactor meltdown in 1986. In all some 26,000 victims (mainly children) have been treated at the Tarará facilities since the first children arrived in March of 1990 (when they were received by President Fidel Castro, emphasizing the importance given the initiative by the government). All medical treatment for patients was provided at no cost to the patients, as was their accommodation and food. This major humanitarian gesture is particularly noteworthy since it was initiated just as the Soviet Union was imploding, resulting in the loss of some 80% of Cuba’s trade, a decline in GDP of some 30%–and the onset of the “Special Period” and its many difficulties. From the Cuban perspective, the timing could not have been worse. For many nations faced with such a profound crisis, it would not have been surprising if the government had swiftly terminated such a broad (and expensive) programme. Yet Cuba did not, again displaying its human capital–and the commitment made to the children of Chernobyl was respected. From several visits to the facility and meetings with the patients and Cuban medical staff it is clear that the attention given to the children was excellent, and the facility–ably managed by Dr. Julio Medina–has done an extraordinary job in difficult circumstances. At its height some 350 people worked at the Tarará facility, which has a small hospital, hundreds of buildings to house the patients, as well as offering educational and recreational programmes for patients. The children were first examined by Cuban medical personnel in their home country, and usually stayed for 45-day periods, although children with more serious ailments were treated by medical staff in various specialized hospitals in Cuba. The objective was, quite simply, to offer high quality medical and humanitarian support to children whose lives had been badly affected by the impact of the nuclear meltdown. In all 21,874 children and 4,240 adults were treated in Cuba, of whom 19,497 were younger than 14, and the most common ailments were related to skin, endocrinological and digestive problems. (5) (At the time of writing Ukrainian President Victor Yankovich had agreed in late 2011 to start paying for those costs, but to date has not initiated payment, and sadly the programme has been placed on hold). Also particularly noteworthy is Cuba’s role in training tens of thousands of doctors from all corners of the developing and underdeveloped world, both in Cuba and abroad. In the wake of the horrendous damage caused in Central America by Hurricane Mitch in 1998, the foundation of the Escuela Latinoamericana de Medicina (the largest medical university in the world with an annual intake of over 1,500 students and with over 9,000 enrolled in the six-year programme) has proved to be an extremely successful vehicle for providing medical care for people who otherwise would have none. To date approximately 10,000 physicians have graduated from ELAM. Over 20,000 foreign medical students are also being trained through the Nuevo Programa de Formación de Médicos Latinoamericanos–although this hands-on method is also being used in a variety of countries, where training is adapted to local conditions and specific needs. Cuban medical professors are teaching in fifteen countries–and are especially numerous in Venezuela. In addition, since the 1970s Cuba has assisted in the founding of medical schools in several countries, including Yemen (1976), Guyana (1984), Ethiopia (1984), Uganda (1986), Ghana (1991), Gambia (2000), Equatorial Guinea (200), Haiti (2001), Guinea Bissau (2004), and East Timor (2005). The role of Cuban medical professors is particularly important in Venezuela, as noted later. Hurricane Mitch (1998) in many ways was the catalyst for a significant development in Cuba’s vastly increased approach to medical internationalism. Some 30,000 people died in that natural disaster, and the Central American leaders appealed to the international community for assistance. Significantly, Cuba did not even have diplomatic relations with the countries affected (several of which had traditionally maintained a policy of hostility to the revolution), yet within days sent 424 personnel to assist the affected areas. This would increase to a maximum of 2,000, before settling at approximately 900 in the region. What was particularly different about the mission in Central America, however, was the decision to help the countries affected to help themselves. Thus was born the central idea of ELAM, according to which students from the region would be trained as doctors in Cuba so that they could return and assist their own people. Cuban medical personnel remained (and still remain), but have gradually seen their numbers decrease as they are replaced by local medical graduates who have been trained in Cuba. In November 1999 the Escuela Latinoamericana de Ciencias Médicas (whose name was later changed to the Escuela Latinoamericana de Medicina) opened its doors to the first students, mainly from the affected region. Most of the students came from poor backgrounds, and approximately one-half were women. The Cuban approach to training foreign students at ELAM is based essentially upon a commitment to train students who could not otherwise attend medical school. The belief is that, since they are not from privileged sectors, they are more likely to return to their communities to work upon graduation, and help their people. In this way it is hoped that the traditional “brain drain” (as graduates from Third World medical schools head to First World countries where the salaries are higher) would be reversed, and that a “brain gain” would result. It is also noticeable how graduates from ELAM who, for a variety of reasons cannot work in their own countries, have also volunteered to work in other countries where there are underserved populations. The best example is Haiti, where students from many Latin American countries are currently working. The lessons of human capital in their six years of training in Cuba have clearly been passed on to thousands of these graduates. In many ways representative of the Cuban level of collaboration throughout the Third World is the broad outreach of Operation Miracle, initiated in 2004. The origins of this wide-ranging ophthalmological programme can be found in the challenges encountered in Cuba’s outstanding literacy plan employed in several countries, (6) when it was discovered that many people were unable to read mainly because of existing medical conditions–mainly cataracts and glaucoma (both easily treated with relatively minor surgery). They were unable to participate in the literacy programme because of deficient eyesight. As a result the revolutionary leadership decided to develop a programme that would allow people to see again, and in particular this approach has spread throughout Latin America. To take one example, in Bolivia alone since 2006 more than 600,000 surgical operations have taken place, mainly for Bolivians but also for citizens of other South American nations bordering that country. Significantly, among the Bolivians treated was Mario Terán, the soldier who executed Ernesto Che Guevara in October 1967. The success of this programme can be gauged by reading some of the articles found in the “Oftalmología” part of the Infomed website. (7) In the section “Más sobre Operación Milagro” there are dozens of articles illustrating the enormity of this programme. To take just a few examples: 15,000 Paraguayans have had their sight restored, 400,000 Haitians have benefited from the programme, 90,000 operations have been carried out in Nicaragua, with almost 200,000 operations in Venezuela… By October 2011 it was estimated by Dr. Reinaldo Ríos, medical director of the Ramón Pando Ferrer ophthalmology hospital in Havana, that the programme had treated over 2 million people in 34 countries of Latin America, the Caribbean and Africa.(8) These operations, carried out by Cuban physicians with Venezuelan support, have been provided at no cost to the patient–the vast majority of whom would otherwise have been unable to pay for these operations. Another extremely important component of Cuban medical internationalism in recent years is the role of the “Henry Reeve” Emergency Contingent. The medical brigade (named after an American participant in Cuba’s first war for independence) dealing with natural disasters and serious epidemics was founded in September 2005 shortly after massive flooding hit New Orleans as a result of Hurricane Katrina. The Cuban government had offered to send 1,586 medical personnel and 36 tons of medical supplies to assist the people of the region, only to have President George W. Bush reject the humanitarian gesture. Within two weeks the “Henry Reeve” International Contingent had been formed, with its goals outlined by Fidel Castro in his speech of September 19, 2005 at the graduation of medical students: “This will take the place of the Medical Force formed to help the people of the United States when Katrina hit the south of the country with all its brutal force. Its aim will not just be to help a certain nation, but to give immediate assistance, with its specially trained staff, to any country that suffers a catastrophe, particularly those that are hit by hurricanes, floods or other natural phenomena of this severity”. The “Henry Reeve” contingent has been involved in 12 missions in countries facing natural disasters, most recently in Chile following an earthquake there. These have all taken place within the space of a few years, a remarkable feat. The largest was to Pakistan (with some 2,250 members), although in many ways the most memorable has been that to Haiti. Cuba has played (and continues to play) an enormously important role in Haiti, both after the earthquake in January 2010 which killed 250,000 and in controlling the cholera epidemic which broke out nine months later. Within two months of the onset of the epidemic almost 150,000 cases had been confirmed, with 3,333 deaths reported.(9) In both cases Cuban personnel assumed the leading role in supporting the Haitian people, and their efforts dwarfed those of the international community. In fact Cuba had been providing a major medical presence since 1998, when Hurricane George devastated the country. Some 500 Cuban medical personnel had arrived at that time, and when the earthquake struck twelve years later there were still 340 Cubans working in the public health sector. In terms of the cholera outbreak, the Cuban-led medical team was bolstered by the arrival of ELAM graduates and upper level students. By April 2011 there were 1,117 members of the Cuban medical brigade, including 923 Cubans and 194 foreign graduates from Cuban programmes. Together they had seen 2 million patients, operated on 36,000, and delivered almost 35,000 babies. A further 465,000 Haitians had benefitted from rehabilitation programmes.(10) Again, their humanitarian efforts of the Cuban mission were (and are) greater than those of all of the industrialized nations combined. To date, however, these contributions remain largely ignored by the international media. Cuba’s role in Haiti has been exemplary. Not only did it provide by far the largest medical contingent at the time of the earthquake, but it also made the greatest contribution to stopping the cholera outbreak, saving thousands of lives. Perhaps most important of all, Cuba is now preparing Haiti for the future by establishing a public health system, financially supported mainly by Venezuela and Brazil. Key to this will be the role of Cuban-trained Haitian doctors, some 625 of whom had graduated from ELAM by early 2011. Of these 430 were already working in Haiti,(11) and later that year another 115 graduated from the Santiago de Cuba campus. An equally important aspect (and in many ways a microcosm of Cuba’s various medical internationalism programme) can be seen in its role in Timor Leste. Cuban personnel arrived after an official request for support in 2003, since as late as 2002 there were only 47 physicians in the entire country. The initial role of Cuban personnel was to provide badly-needed medical support in a country still recovering from its independence struggle and invasion by Indonesian armed forces. Within the first five years of the arrival of the Cuban brigade more than 2.7 million medical consultations had taken place, with an estimated 11,400 lives saved. The next phase of Cuban cooperation in the country was to train Timorese youth to become doctors, and take care of their own people. By 2008 “there were some 350 Cuban health workers in the region, with 870 East Timorese and more than 100 Melanesians and Micronesians engaged in medical training”.(12) Most received their basic training in Cuba, and then returned to Timor, although increasingly the objective is to train them in their homeland, where a Faculty of Medicine (staffed by Cuban professors of medicine) was established in 2005. Once again the common theme of providing Cuban medical support initially, and then developing local talent to replace Cuban specialists and assume medical responsibilities, has been successfully employed. Human capital has thus been transplanted to this country, and is in turn being expanded to other small countries in the South Pacific. Comparable to the efforts in Timor Leste, although on a much larger scale, has been Cuba’s medical cooperation in Venezuela, where at present the largest contingent of Cuban medical personnel is found. The contribution of almost 30,000 Cuban medical personnel in Venezuela started in 1999 following massive flooding in the state of Vargas. Some 15,000 people died or disappeared, and within a week over 450 Cuban medical personnel arrived to support the initiatives of newly elected president Hugo Chávez. Four years later the municipality of Libertadores in Caracas, noting the major public health deficiencies in the area, appealed for medical support from Venezuelan doctors. Most refused, citing concern over their personal security, leading President Chávez to then approach Havana–and as a result in April 2003 Cuba sent 53 family physicians. It is important to recognize the determination of Chávez to use the nation’s petroleum wealth for the benefit of the country as a whole, and particularly marginalized sectors traditionally excluded from such services. It is also worth emphasizing the level of bilateral cooperation that resulted within just a few years. The original mission to Libertadores was extremely successful, resulting in the decision to expand the programme to the country, and ultimately the various stages of Misión Barrio Adentro. The growth in the number of Cuban medical personnel was extraordinary. According to Chávez, from just 53 doctors in April 2003 this had increased by November 2010 to a situation in which Cuban personnel were staffing 6,172 consultorios médicos populares, as well as working in 3,019 dental positions, 459 ophthalomology posts, 514 Centros de Diagnóstico Integral clinics, 559 Salas de Rehabilitación and 28 Centros de Alta Tecnología. (13) In addition to Cubans treating Venezuelan patients in their own country, over 51,000 Venezuelans have also received specialized medical treatment in Cuba.(14)By April of 2012 it is estimated that Cuban medical personnel had provided over 745 million free medical consultations, with over 1.5 million lives being saved.(15) (This refers to people who, if adequate medical support had not been provided and based upon traditional mortality patterns, would probably have died). Preparing for the future, Venezuela is seeking to emulate Cuba’s ELAM–and, with the support of Cuban medical professors, is training over 30,000 physicians. In February 2012 the first cohort graduated–8,150 specializing in Medicina Integral Comunitaria (MIC); a further 6,300 are soon due to graduate, having completed the 6-year programme. At present, according to Chávez, some 22,604 students are studying MIC in Venezuela, and this will clearly make a significant contribution to the public healthcare system.(16) It is worth noting that none of this could have happened without strong bilateral ties, and extraordinary Cuban cooperation in the national medical system. At times Cubans complain about their family doctor participating in an internationalist mission, or having to walk further to the local consultorio, because there are so many medical personnel are abroad. It is worth noting, however that, while approximately 20% of Cuban physicians are indeed working abroad, the ratio of doctor to patients in Cuba is still probably the best in the world. A comparison with other countries is pertinent in this analysis. In Canada there were 2.4 physicians per 1,000 population,(17) and 2.4 in the United States in 2009, whereas in Cuba there were 6.7 in 2010, according to World Bank data.(18) Moreover the distribution of medical attention to Cubans is far more equitable than Canada (and indeed most industrialized countries, including the United States), where a number of physicians work in the private sector (making medical care inaccessible for many), and where few physicians work in rural areas. While increased distances to visit a médico de familia and longer waiting times might bother Cuban patients (since so many physicians are in Venezuela), they are still in an enviable situation–far better than any other country in the world in terms of accessibility. As a result, the approximately 100,000 barrels of oil received daily in Cuba (and with preferential prices) in exchange for professional services, make this relationship mutually beneficial–as anybody who remembers the dark days of the “Período Especial” can attest. (19) One of the most recent programmes undertaken by Cuban medical internacionalistas has been the survey of the population of ALBA countries to ascertain the level of physical and mental challenges of their populations, carried out by hundreds of Cuban medical personnel in member countries of ALBA. Cuba had already carried out a similar medical survey within its own territory, arguing that this detailed analysis was needed in order to both have a full understanding of challenges facing individual members, and prioritize the medical needs of these patients. In the case of Venezuela (where in 2008 Cuban medical personnel–including a large pool of geneticists and social psychologists– worked with local health brigadistas) in the Misión José Gregorio Hernández, some 600,000 patients were identified as having special needs–and the government moved to meet those specific concerns. The purpose of these campaigns was thus not just to undertake a detailed survey, but rather to undertake a scientific study to determine the causes of the particular “discapacidad” and to provide the needed assistance to the persons affected. Since 2009 other countries belonging to ALBA have also benefitted from this detailed project. This was a massive undertaking, with over 71,000 specialists (Cubans together with specialists from each of the countries involved) working on the project, going door-to door, and visiting over 3,800,000 homes in Venezuela, Bolivia, Ecuador, Nicaragua and Saint Vincent and the Grenadines.(20) By July of 2011 a total of 1,017,464 people with special needs had been identified in the ALBA countries where the research had been carried out. In Bolivia this campaign was known as the Misión Moto Méndez (named after a 19th century guerrilla), involving Cuban, Venezuelan and Bolivian physicians, and as a result of the intensive campaign some 83,000 people with physical and mental challenges were discovered. The Misión Solidaria Manuela Espejo had a similar goal–to undertake a bio-psycho-social scientific study, in order to determine the causes of the problems facing Ecuadorians, and the needs that they faced. In all 229 Cuban medical specialists and 129 Ecuadoreans visited 1,286,331 homes, and listed 294,611 persons with special physical or mental needs. Significantly, by January 2012, a total of 265,515 technical supports had been given to 135,254 of these people.(21) Any one of these various programmes of medical cooperation would be extraordinary for a country of the size and wealth of Cuba. Indeed no industrialized country has ever attempted to undertake any one of such ambitious healthcare initiatives. But to see the combination of so many humanitarian initiatives being enacted is truly extraordinary. Just as important is the recognition that these programmes have been ongoing for five decades. In the case of Africa, to take just one example, while there are currently some 5,500 Cuban professionals working there, almost 40,000 Africans have graduated from Cuban universities, and there are currently 3,000 studying in Cuba.(22) With justification Nelson Mandela summarized well the Cuban contribution in his visit to Havana in 1991: “Venimos aquí con el sentimiento de la gran deuda que hemos contraído con el pueblo de Cuba… ¿Qué otro país tiene una historia de mayor altruismo que la que Cuba puso de manifiesto en sus relaciones con África?”.(23) In the case of Latin America the data are even more surprising, since particularly during the last twenty years Cuba has provided tremendous levels of cooperation with countries of the region. Once again human capital has been employed to the full–saving countless lives in the process. All of this poses the logical question: why does Cuba continue to provide this far-reaching collaboration? One reason put forward is that Cuba is seeking to exercise what is known in North American academic circles as “soft power,” that is co-opting countries by showering them with positive support and benefits in exchange for future considerations from them. At first glance there would appear to be some validity in this argument. Indeed it is obvious that Cuba’s programme of medical internationalism–even in countries with which it had enjoyed difficult diplomatic relations–has resulted in a clear softening of opposition by those governments, and ultimately to a normalization of relations. After all, how can you not have diplomatic relations with a country whose doctors are saving thousands of your compatriots’ lives? It is particularly significant that Cuba has not provided medical cooperation solely to countries with similar ideological convictions. Mention was made earlier of the first mission to Alessandri’s Chile in 1961 and, also almost 40 years later, of the extensive Cuban collaboration with Honduras and Guatemala (after Hurricane Mitch), countries which had been strong US allies, and had traditionally condemned Cuba. El Salvador, under a number of military governments, was also a major ideological foe of the Cuban revolution, yet Havana did not hesitate in sending 22 tons of emergency medical supplies following an earthquake there in 1986. Likewise it sent a large medical delegation in 2000 to assist when a major outbreak of dengue occurred. In addition Cuba also provided medical support to Somoza’s Nicaragua after an earthquake devastated the capital in 1972. No other Latin American president had been as opposed to the Cuban revolution as Anastasio Somoza, and indeed in 1961 he had allowed mercenaries to leave from Nicaraguan ports in the abortive invasion of Playa Girón. As an extension of this approach it is also argued that the Cuban government pursues this policy to obtain votes of support at the United Nations (which in 2011 saw 186 nations condemn the US economic embargo of Cuba). In a May 2007 interview by the author and Michael Erisman with Dr. Yiliam Jiménez, this argument was answered well: “Y si aun aceptamos la perspectiva más cínica–o sea que Cuba manda médicos a países pobres para ganar votos en la ONU, ¿por qué los países industriales no hacen lo mismo? Lo más importante es salvar vidas–y eso es precisamente lo que hace nuestra política”. Her argument is completely correct. So far the lack of similar commitment to “salvar vidas” on the part of the G8 nations is sadly absent, while consistently Cuba has placed humanitarianism before ideology. It is also abundantly clear that the major driving factor behind these initiatives for decades has been the revolutionary leadership, and in the particular the long-term vision of Fidel Castro, for whom access to public healthcare has always been an extraordinarily important issue–the most basic human right. From interviews with Cuban policy-makers during the course of this research it is obvious that his was the principal initiative in all of these programmes. The political will to undertake these health campaigns, to mobilize human resources and ensure adequate funding, thus came as a result of a political and humanitarian decision taken by the presidency. For a foreigner examining this complex, multifaceted phenomenon, it is also clear that the development of a finely-tuned conciencia socio-política on a national level is also an extremely important base, allowing acceptance of these far-reaching policies. The successful medical internationalism programme over the years has also supported the sense of national identity, strengthening the profound sense of nationalism and national pride that are extremely noticeable in Cuba. This is supported by the Cuban Constitution itself which notes the commitment to “el internacionalismo proletario, en la amistad fraternal, la ayuda,a la cooperación y la solidaridad de los pueblos del mundo, especialmente los de América Latina y el Caribe”. The profoundly-rooted sense of international solidarity–which was found as early as the struggle for independence in the late 19th century–is also a key psychological factor. Cuba was assisted in the second half of the 20th century by other acts of solidarity from foreigners, from the key role of Ernesto Che Guevara to the economic support of the countries of COMECON, and in more recent times from Venezuela. The combination of decades of participating in internationalist missions, or having friends and family members do so, has resulted in a process of profound socialization in respecting such humanitarian initiatives. It is also true that the exportation of professional goods and services is the largest single source of hard currency for the Cuban economy, far outstripping tourism and nickel. Estimates for the amount of income derived from medical services abroad range from $3 billion to $8 billion annually. The most recent estimate is $5 billion, roughly double the earnings from the successful tourist industry.(24) Whatever the amount, it is still the largest generator of hard currency for the government, and remains as a priority of the Cuban government. With arguably a surplus of medical personnel (a position often denied by members of the revolutionary leadership, who claim that there is never have an excess of doctors), this use of trained medical cadres is an enormously successful economic policy. The government of Raúl Castro has moved to reduce some of the benefits earlier enjoyed by both internacionalistas (lifelong financial supplements) and beneficiaries (North American students at ELAM no longer study for free, the Ukrainian government is expected to pay for treatment of children affected by the Chernobyl implosion, and foreign students are now expected to pay for further specialization). In addition the government has made it clear that it is interested in expanding the medical tourism operations in Cuba, and to send Cuban personnel to wealthy countries. This is illustrated by the Cuban role in Qatar, where in early 2012 a 75-bed hospital staffed by some 200 Cuban medical personnel was inaugurated in Dukhan. In sum, while Cuba’s medical internationalism for poorer countries remains intact, there is a growing determination to increase profits from the exportation of medical goods (clearly seen in the impressive growth of the biotechnology sector) and services. On a personal level–that of the internacionalistas themselves–in the course of interviews for my research it has been interesting to see the explanations given by them for their involvement in missions abroad. The majority explain that they participate in medical missions for financial reasons since it allows them the opportunity to earn several times their salary during their Internacionalista experience than they would if they remained in Cuba. While it is extremely difficult to be away from family for long periods of time, most welcome the chance to earn a greater income, which allows them to purchase goods in Cuba that otherwise they could not afford. (Most contracts are for 2-year periods, although members of the mission generally return for a month midway through their stay abroad). Since the start of the Special Period, there is an inverted pyramid in terms of salaries, with those employed in the tourist trade–even in positions where no further education is required–earning far more than professionals with advanced degrees. Internacionalista missions thus allow participants to redress in part at least some of that imbalance. Others have noted that the medical experience abroad in underdeveloped countries represents an excellent opportunity for them to develop their professional medical skills, since they deal with situations that are often totally new to them. From malnutrition in Gambia to gunshot wounds in Guatemala, the experience allows them to expand their medical knowledge, to become better doctors and nurses. Several others interviewed also refer to this experience as a kind of rite of passage, something that almost all medical staff in Cuba do at some point in their life. In sum, there are many different reasons–ranging from genuine altruism to personal gain, from a decades-long tradition of service to the possibility of income-generation. Whatever the motives of individuals or the revolutionary government, there is no doubt that these five decades of medical cooperation have made an enormous contribution to the wellbeing of the Third World. Any one of these (many) significant medical contributions would be truly noteworthy, particularly since Cuba is a small country, with severe economic constraints. However, when seen in their entirety, they represent a truly extraordinary contribution to the wellbeing of dozens of countries around the globe. Writing in 2010, Julie Feinsilver offered a succinct summary of the significance of this contribution. She noted how Cuban internacionalistas have “saved more than 1.6 million lives, treated over 85 million patients (of which over 19.5 million were seen on house calls at patients’ homes, schools, jobs, etc.), performed over 2.2 million operations, assisted 768,858 births, and vaccinated with complete dosages more than 9.2 million people” (25) Whether it be to Alessandri’s Chile in 1960, Somoza’s Nicaragua in 1972, or even George Bush’s United States in 1995 (when an offer of some 1,500 Cuban medical personnel in the wake of Hurricane Katrina was rejected), the same commitment to assist humanity has been consistent. Mention was made earlier of Fidel Castro’s speech at the founding of the “Henry Reeve” Brigade. In it he also referred to the need to respond to natural disasters, regardless of the ideology of the country: “Not once, throughout the selfless history of the Revolution, have our people failed to offer its supportive medical assistance to other nations in need of this aid at times when catastrophes have hit them, regardless of wide ideological and political differences, or the serious insults received from the government of any of these countries”. In essence Cuba has provided an example for the planet, showing how its successful medical collaboration programmes have been far more successful, and more far-reaching, than anything provided by all of the G-8 countries’ efforts combined. For over fifty years Cuban medical personnel have served the poorest and most neglected areas of the world, going where other doctors refused to go. At present they are looking after the wellbeing of some 70 million people. The root of this contribution is the same “human capital” found in Chile in 1960 and in each of the 66 countries where they are currently working. Indeed their work–overlooked by the media in industrialized nations– puts the “developed” countries of the world to shame… John M. Kirk is a Professor in the Department of Spanish and Latin American Studies at Dalhousie University, Halifax, Canada. NOTES 1.This research project is supported by funding from the Social Science and Research Council of Canada. I would like to thank the Council for financial support. I would also like to recognize the support of Dr. Víctor Manuel Rodríguez, of the International Relations sector of MINSAP, and Dr. Arturo Menéndez Cabezas, currently working in Barcelona, Venezuela. I would also like to thank Emily Kirk, of the University of Nottingham, for her helpful comments. 2.Data provided by Dr. Yiliam Jiménez, director of the Unidad Central de Cooperación Médica of MINSAP, in a Prensa Latina report of April 3, 2012, “Colaboración médica cubana, gratituidad y acceso universal”. 3. “Alrededor de 5,500 profesionales cubanos prestan servicio en África,” Cubadebate, June 5, 2010. 4.Cited in Piero Gleijeses, Misiones en conflicto. La Habana, Washington y África, 1959-1976 (La Habana: Editorial de Ciencias Sociales, 2002), p. 28. 5.Data obtained from report (“Pograma cubano de atención médica integral a niños relacionados con el accidente de Chernobil”), received from Dr. Julio Medina, director of the programme in Tarará, and from an interview with him in December 2011. 6.The literacy programme has been used in 29 countries, teaching basic literacy to 6.5 million people, according to Pedro Rioseco, “Desarrollo exitoso del programa alfabetizador ‘Yo sí puedo,’” Prensa Latina, May 24, 2012. 7.See “Más sobre Operación Milagro,” located at http://www.oftalmologia.sld.cu/mas-sobre-operacion-milagro. 8.See “Misión Milagro ha beneficiado a dos millones de pacientes,” Radio Santa Cruz report, October 8, 2011. 9.Conner Gorry, “Haiti One Year Later: Cuban Medical Team Draws on Experience and Partnerships,” MEDICC Review, vol. 13, no. 1 (Jan 2011), p. 52. 10.See “Bruno Rodríguez en ONU: La reconstrucción de Haiti es tema pendiente,” Cubadebate, April 6, 2011. 11.Gorry, p. 53. 12.Tim Anderson, “Cuban Health Cooperation in Timor Leste and the South West Pacific,” The Reality of Aid: Special Report on South-South Cooperation 2010 (Quezon City, Philippines: IBON, 2010), p.77. 13.For further analysis, see John M. Kirk, “Cuban Medical Cooperation within ALBA: The Case of Venezuela,” International Journal of Cuban Studies, vol. 3, nos. 2/3 (Summer/Autumn 2011), p. 231. 14. “Un paso gigante por la vida,” Juventud Rebelde, May 31, 2012 15.René Tamayo, “Una misión de vanguardia,” Juventud Rebelde, April 17, 2012. 16.René Tamayo, “Primera graduación de médicos integrales comunitarios de Venezuela,” Juventud Rebelde, February 16, 2012. 17.Patrick Sullivan, “Canada’s MD/Patient improves but low international ranking continues,” Canadian Medical Association, February 12, 2012 (See http://www.cma.ca/md-patient-rate-improves Accessed May 31, 2012). 18.See “Physicians (per 1,000 people)” at http://data.worldbank.org/indicator/SH.MED.PHYS.ZS Accessed May 31, 2012). The website of the Oficina Nacional de Estadísticas in Cuba notes that in 2010 there were 76,506 physicians in the country, with an average of 1 physician for 147 patients. See http://www.one.cu/aec2010/esp/19_tabla_cuadro.htm. 19.Dr. Jiménez has summarized this relationship well: “We believe in fair trade. If that means that we export a product that we have surplus of–in this case educational goods and services–to a friend at a reduced price, and they export to us at favorable conditions something that they have in abundance–petroleum–what is wrong with that?”. See John M. Kirk and H. Michael Erisman, Cuban Medical Internationalism: Origins, Evolution and Goals (New York: Palgrave Macmillan, 2009), p. 186. 20.Data taken from two reports, “Destacan resultados de estudio sobre discapacidad en países del ALBA,” Cubadebate, July 7, 2010 and “Exitoso estudio cubano de discapacidad en países del ALBA,” November 27, 2010, found at nttp://www.tvcamaguey.co/cu/index.php?view=article&catid=43%3Asalud&id=6054%3Ae.. 21.Data taken from “Misión solidaria Manuela Espejo,” n.d., issued by the Office of the Vice-President of Ecuador and found at http://www.vicepresidencia.gob.ec/programas/manuelaespejomision. 22. Data taken from comments by Deputy Minister of Foreign Affairs, Marcos Rodríguez in “Alrededor de…,” Cubadebate, June 5, 2012. 23. Gleijeses, p. 458. 24.Fernando Ravsberg, “May Day in Cuba: The Doctors Out in Front,” Havana Times, May 2, 2012. 25.Julie Feinsilver, “Cuba’s Health Politics: At Home and Abroad,” Report prepared for the Council on Hemispheric Studies, March 2010 (http://www.coha.org/cuba/%e2%/80%99s-health-politics-at-home-and/abroad. Accessed September 20, 2010)