The Miami Herald
Sunday, August. 17, 2008

Cuba reaps goodwill from doctor diplomacy


She said she'd be wearing a short jean skirt and a red top. She said she'd be alone, somewhere near the second-floor cafeteria of a large supermarket where her colleagues, Cuban doctors like her, were unlikely to be: None of them can afford the $3 it costs to eat a plate of rice, a slab of meat and potato salad -- the dish of the day today -- washed down with a carton of mango juice.

The meeting is set for 2 p.m. And right on time, she walks in, barely glancing at the shelves stacked with products she is dying to try but can't. She is saving her money to escape to the United States.

''For me, this is nothing but a way out,'' said the doctor, an internist who is afraid to speak openly about her plans to defect and begged that her name not be used. ``I can't wait to get out of this place.''

Meet the Cuban doctor, the most widely deployed and effective ideological and diplomatic weapon in the almost 50 years since Fidel Castro seized control of the island. And, in the past few years, the most profitable export of the country's economy.

Although thousands of doctors have defected over the years, and others, like the doctor in the red top, are planning to do the same, more than 72,000 remain on the island and scattered all over the world, and more are in the pipeline.

Cuba churns out doctors like no other nation in the world -- it boasted one doctor for every 159 people in 2005, according to official Cuban estimates. By comparison, in 2000, the United States had about one doctor for every 414 citizens, according to the most recent figures on the World Health Organization's website.

But the doctor-to-citizen ratio in Cuba has decreased greatly because so many have been sent on international missions, a much coveted posting for doctors who make an average of $25 a month at home.

Despite the increasing risks of defection -- since 2006 the United States has made it easier than ever for Cuban doctors to abandon their posts by offering them U.S. visas from consulates wherever they defect -- Cuba seems to be relying more than ever on its vast health industry for income.

Julie M. Feinsilver, a Latin American scholar and author of Healing the Masses: Cuban Health Politics at Home and Abroad, maintains that Cuba is the only country that ``has developed doctors as an export commodity.''

''Fidel looked at it as a politician,'' Feinsilver said. 'Raúl is much more pragmatic; he's looking at it as a manager: `I have this huge industry. What makes sense? How should I use it?' ''


In the past four months alone, Cuba has inaugurated the first of seven ophthalmology hospitals that it plans to open in Algeria, staffed only by Cubans; it opened the second of at least three centers of the same kind planned in China; and it has made a commitment to staff with Cuban doctors a hospital in Qatar, Spain's La Vanguardia newspaper reported in June.

And in July, Cuba's national magazine, Bohemia, reported on its online pages that the country earned about $350 million last year from the sale of medicines abroad, second only to nickel and surpassing more traditional exports such as tobacco, rum and sugar.

More than 31,000 Cuban health workers -- most of them doctors -- who toil in 71 countries brought in $2.3 billion last year, Feinsilver said, more than any other industry, including tourism.

Most of them are paid $150 to $375 a month, a small percentage of the cash or trade benefits the Cuban government pockets in exchange for their work, she added.

The largest Cuban medical mission is in Venezuela, where anywhere from 22,000 to 30,000 health personnel have been working since 2003 in exchange for cheap oil and other trade benefits. Their presence here is an irritant for those who see in President Hugo Chávez a clone of Fidel Castro, but a relief for Venezuelans who see the doctors as the only way to receive free healthcare right in their own barrios.

''If it weren't for the Cubans, I don't know what I'd do,'' said Sosnelly Zarraga, a 23-year-old cosmetics saleswoman, who was waiting for a free blood test outside a diagnostic center in Petare, one of Caracas' poorest and most violence-ridden areas. ``I'd have to pay a week's salary to get the same service.''

That is precisely the kind of reaction that irks Milos Alcalay, a former Venezuelan ambassador to the United States and a critic of Chávez and of the Cuban presence in his country. ''The gift'' of the Cuban help to Venezuelans, he said, can only be compared to a Trojan horse.

''Behind the fac¸ade of humanitarian help comes ideology,'' Alcalay said. ``The fact that they are here is in itself political. These doctors have become Cuba's new soldiers, like the ones who went to Angola 30 years ago, but bullets no longer work. If Cuba were to send us soldiers, Venezuelans would recoil. But who is going to refuse a doctor?''

Since 1960, when the first batch of Cuban doctors were sent to aid Chileans after a powerful earthquake there, about 1,000 Cuban medical personnel have been sent on emergency relief missions to 20 countries -- including, most recently, 36 who went to China after the earthquake in the province of Sichuan in May.

In addition, 113,585 health professionals -- doctors, nurses and technicians -- have been deployed to 103 countries in missions that have lasted anywhere from a few months to years in places as close as Haiti and as far from Cuba as Kiribati, a 280-square-mile nation in the Pacific Ocean. Cuba even offered to send doctors to the United States in 2005 for Hurricane Katrina relief; the State Department declined the offer, saying that a sufficient number of U.S. doctors had offered to help.

Armed with nothing but white coats and their medical and political training, these doctors have been Fidel Castro's most effective weapon -- more so than bullets -- to spread the ideas of the revolution to all corners of the world, and to foster goodwill among people too poor to question why a small island in the Caribbean sends doctors to cure their ailments, but also too grateful to ever forget their nationality.

Take the story of Sahlu Merine, who was 12 when he met Cuban doctors in the largest hospital in Addis Ababa, the Ethiopian capital. Although he said he didn't need medical help from them, he has only warm feelings not only for the doctors but also for the government that sent them.

''I chose not to forget those who helped us,'' said Merine, the business manager of a private school in New York. ``Healthcare is the most important human right. And when we needed them, the Cubans were there. It has colored the way I see Cubans and the way I think about their government and their country.''


The strategic deployment of doctors to the world's toughest places has garnered Cuba praise and much goodwill. As Feinsilver notes in her book, that goodwill has contributed to the island's election to leadership positions in many international organizations from the late 1970s to the present, including the Non-Aligned Movement and the United Nations Security Council.

Cuban poet and former political prisoner Armando Valladares, who headed the U.S. delegation to the U.N. Human Rights Commission in the late 1980s, said he remembers several instances in which members of African and Latin American delegations told him they couldn't vote for proposals to send human-rights investigators to Cuba because they feared losing the help that Havana had provided to their countries or because they felt indebted to the Cuban government.

''And if you put yourself in their places, you realize they are right,'' Valladares said. ``Without a doubt, the health issue has been one of the most effective propaganda tools on behalf of the Cuban government. The doctors go to places where others won't go -- isolated, poverty-ridden villages and towns.''


Cuban doctors in Venezuela are well aware of the dichotomy of their role. On the one hand, they are serving the poor in this rich nation that keeps the Cuban economy afloat. On the other, they are also serving their own interests, which often run contrary to the ideas of the regime that trained them as doctors and tried to mold them as revolutionaries.

The doctor in the red top, for example, said she relishes the opportunity to care for the poor here, and, she said, she couldn't imagine charging a human being who couldn't afford to pay for treatment. At the same time, and without pausing to contemplate the contradictions in her thought process, she dreams of becoming a doctor in the United States, where, she knows well, many people are uninsured and healthcare is in a crisis often cited as one of the top issues in the presidential campaign.

Julio Cesar Lubián, a 46-year-old doctor who is no longer afraid to speak to reporters because he defected 14 months ago, shares the same dream: to live and work in the United States.

''Anybody who tells you they came here to work because of ideology is lying to you,'' said Lubián, sitting at a cafe in a park two hours outside Caracas. ``Everyone is here to send money home, to earn dollars or to find a way out.''

It is nearly impossible to speak with doctors who are working here in what the Chávez government calls the Barrio Adentro Mission, about to mark its fifth anniversary next month. Among other limitations, they are expressly forbidden to speak to members of the media. Cuban officials in Caracas did not reply to a Miami Herald request for an interview.

A copy of the rules that Cuban doctors here must follow, obtained by The Miami Herald, reveals that they are treated like soldiers and are expected to behave as such.

Many work in their homes, seeing patients downstairs and sharing tiny sleeping and living quarters upstairs. They are expected to inform their supervisors if anyone offends the ''honor of the motherland and its symbols'' in their presence and forbidden to stay out overnight.

Although the rules also say that they must not offer any ''opinion about political events'' in Venezuela, the ideological component of their mission is impossible to escape. Posters of Che Guevara, Fidel Castro and Hugo Chávez can be found in most, if not all, of the octagonal buildings that house the Cuban-run clinics here.

In the large diagnostic and rehabilitation centers, elaborate but crudely made displays -- such as the one a second-grade student can create for a history project -- hang from the walls. Many include pictures of a youthful and armed Castro, and some compare his 26th of July movement and the 1953 attack on the Moncada barracks to the war that Chávez has declared against poverty, disease and despair. Health is depicted as another war to wage, another victory against the United States.


Frank Cabrera, 30, a doctor who shortly before his defection two years ago was one of the mission's leaders in the state of Zulia, said that Cuban Communist Party leaders who supervise the brigade in Venezuela asked him and other doctors to secure at least 20 votes for Chávez in the 2004 election. He said he didn't do it, but he didn't have to.

''It is as simple as this: You begin distributing vitamins to the population in a crucial time in the elections,'' said Cabrera, who now lives in Miami. ``People know who delivers the vitamins, they know where they come from, and they know who's paying for them, so they quickly decide who they vote for if vitamins are important for them. And for most people, they are.''

Yet, for some pro-Chávez Venezuelans, the Cuban involvement does not go far enough.

Rubén Martínez, a social worker in charge of the Barrio Adentro Mission in the municipality of El Libertador in Caracas, said too many doctors have left for other missions in Pakistan or in Bolivia or to staff larger medical centers in other parts of the country, so that of the 1,146 assigned to Caracas five years ago, only 400 remain.

And those, he said, don't do the kind of political indoctrination he thinks Venezuelans need.

''This is a consumer's society, a bourgeois society,'' Martínez said. ``There is much we could learn from the Cubans if only they would be willing to teach us, but they are too busy already.''

A typical day for a Cuban Barrio Adentro doctor here begins early in the morning, seeing patients. Some have to walk for miles under the sun and up and down hills to check on patients who are housebound or who have lost their neighborhood doctor to another mission. They eat whatever they can cook from their government-issued rations: rice, oil, beans, flour, sugar, powder milk, sardines, chicken, butter, mayonnaise, coffee and canned meat.

They can't accept gifts, or go to the movies, a bar or a disco. To have friends outside of work, they have to ask permission from their supervisors. They have to attend political meetings where news from Cuba and world events are discussed. They can't drive or visit another state, or have opinions that are contrary to those of the government or its healthcare system. By 7 p.m. or so, they should be home -- for their safety, they are told.

Several Cuban doctors have died in Venezuela, victims of crime. The numbers are hard to pin down. Martínez said he knew of four who had been murdered, but some of the doctors here say the number is higher, perhaps 14.


The doctor with the red T-shirt finishes her lunch and after a two-hour talk asks to be driven back to her home. Her roommates may notice her absence, and she does not want to raise suspicion. She is so highly regarded by her peers, she said, that she has been appointed to a supervisory role. Often, she said, she attends meetings, where she keeps quiet and tries not to roll her eyes at the rhetoric.

''If they only knew what I'm thinking,'' she said. Her most obsessive thought: how to escape. She needs about $2,000, she said, for a plane ticket and a place to stay after defecting and before she receives a U.S. visa.

She politely refuses an offer for dessert or coffee. Her nerves are shot and she can't eat. Just take her home, she pleaded. She asked to be dropped off at the corner, away from the prying eyes of neighbors and colleagues.

``Peor que en Cuba,'' she whispers as she leaves the car. ``Worse than in Cuba.''