Short abstract
Thousands of Cuban doctors are working on government health programmes abroad. Sara Carrillo de Albornoz reports
The US government's opening of its doors last week to Cuban doctors working in third countries (BMJ 2006;333: 411, 26 August16931834) threw light on the number of medical personnel from Cuba who are sent abroad on government schemes. The Cuban health system is promoted by its Communist government as one of the best in the world, with its free access to care and improving health indicators that are similar to those in western European countries.
Figure 1.
Cuban doctor Vivian Iglesias working in a shanty town in Caracas, Venezuela
Credit: FERNANDO LLANO/AP
About 20 000 Cuban doctors are currently working abroad on international missions. Many of them are in Venezuela, whose president since 1999, Hugo Chávez, is a close ally of Castro. Central to Chávez's health policy is the project Misión Barrio Adentro [Into the Neighbourhood], which provides health care for people from poor rural areas and urban slums.
Otto Sanchez, a Cuban doctor working in Miami, is a member of Solidarity Without Borders, a Miami based organisation that helps Cuban doctors who have defected. He worked in Venezuela but defected, via Colombia, to the United States two years ago.
He said, “We were placed in slums with a high level of violence, under constant monitoring by the Bolivarian brigades [political police], who are supposed to offer protection but also report any suspicious activities and assure that we carry out our `revolutionary' duty, indoctrinating our patients to vote for Chávez. If we refuse to do so we are sent back to Cuba.”
Cuban doctors in Venezuela are under continual pressure, he said. “Chávez's officials consider us possible defectors and monitor us constantly. The Venezuelan opposition accuse us of acting as a propaganda machine, and Venezuelan doctors complain that we are taking their jobs.”
At the moment, with the change in US immigration policy, it is even more difficult to defect if you are in Venezuela, said Dr Sanchez. Vigilance surrounding the US embassy in Caracas—where doctors might seek asylum—and the borders has been increased since the policy change.
Dr Sanchez accepts that the Cuban doctors are having a positive effect on Venezuela's primary health care. He said, “People from the barrios had never had access to health care. They had to walk and wait for hours to see a doctor. Now they have Cuban doctors and Cuban medicines next door.”
However, he says the opposite is true in Cuba, where one in five local surgeries has been forced to close as a result of a lack of medical personnel and supplies.
So, has Castro's policy of international missions undermined health care in Cuba? The country has struggled for years with a US blockade limiting the supply of drugs and equipment, yet it has developed a significant biotechnology and pharmacological industry and moved into health tourism as a way to gain US dollars.
Luis Carlos Da Silva, editor of the Cuban public health journal Revista de Salud Publica, said, “After the fall of the USSR and the strengthening of the US embargo Cuba experienced a huge decline in its imports and exports and a severe crisis of energy and health resources.
“In recent years our pharmaceutical and biotechnology industries have recovered, and we have successfully reorganised primary and secondary health centres.”
Dr Sanchez, meanwhile, is surprised at these claims. “Hospitals for foreigners always have the latest equipment and drugs,” he says. “It is heartbreaking to feel like a second class citizen in your own country.”
Javier Ludeña from Medicos del Mundo, a Spanish non-governmental organisation that collaborates with the Cuban health authorities on a programme to prevent sexually transmitted diseases and AIDS, supports the health tourism initiative. “The revenue goes directly towards the Ministry of Public Health's budget and is then invested in the public health system,” he said. “Health is the top priority for the Cuban government.”
Dr Da Silva acknowledges that the international missions had sometimes created tensions in primary care in Cuba. “Many doctors had to increase their working hours to cover for those who are abroad, but the balance is clearly positive. The fact that the health indicators have kept on improving confirms that this collaboration is positive for the citizens of Cuba.”
One doctor in Cuba who has broken ranks is Hilda Molina, founder of the country's Centre for Neurological Restoration. A former member of the Cuban parliament, she quit her position after the government proposed turning the centre into an exclusive, foreigners only institution. She says in a document presented by the Centro para Apertura y Desarrollo de America Latina (www.cadal.org), a non-governmental organisation based in Buenos Aires that aims to promote democracy and economic development in Latin America, that she has not been allowed to leave Cuba and has lost all sources of income, having to survive on money sent by her son in Argentina. “They say my brain belongs to the country,” she said.
Dr Molina warned that Cuba's medical statistics are manipulated by the government. But Colin Mathers of the World Health Organization defended the statistics: “Various groups within WHO collect data relating to Cuba: some from the Cuban government, some from peer reviewed articles, and some from other monitoring and research projections.” He said that WHO addressed issues of “quality and consistency of methods and definitions.”
Dr Sanchez said, “Cuban doctors practise an old fashioned medicine where the medical history and physical examination are exhaustive, as diagnostic tests are not always available.
Dr Molina sums up the last 50 years: “All this has had a psychological impact on health professionals, who feel disappointed, tired, and powerless.”
The BMJ contacted the Cuban health ministry for its comments but had received no reply when the journal went to press.