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Medical Diplomacy Wins Friends But Also Makes a Few Enemies

Medical diplomacy primarily wins friends among the governments whose people receive the aid and the patients and students who directly and individually benefit from it. But not all are thrilled to have Cuban doctors in town. In particular, local medical associations and individual doctors have harshly criticized the Cuban presence because of their competition for jobs, their different manner of working and treating patients, and because of the perquisites they receive (principally, free room and board). In some cases, such as in Bolivia and Venezuela, these medical associations have gone on strike to protest the Cuban presence. In these and some other cases, such as in South Africa and Haiti, they have taken their complaints to the press. Despite protests (and strikes), numerous press and other reports from different countries extol the benefits to the patients, many of whom had never seen a doctor before, particularly living and working in their own neighborhood.

Not surprisingly, these medical associations sometimes seek to discredit the Cubans and use what appears to be a technical argument, the questioning of certification standards (credentials) and quality of care. Medical licensing is a standard practice in all countries, but it can be and is used by some who feel threatened by the competition of Cuban doctors willing to serve in areas that they themselves would not go, let alone work. On the other hand, standards are important and ideally, there should be a WHO or other supra-national independent accreditation agency that could establish criteria for and validate medical degrees and licenses or establish equivalences so as to eventually allow for global labor mobility. This, however, would be extremely difficult to negotiate and is unlikely to occur in the next few decades. Therefore, Health Ministries, or, in some cases, medical associations become the gatekeepers for entry into the profession. This is tricky when vested interests are in charge of the licensing or accreditation process or are politically strong enough to block it. In 2003, the Venezuela Medical Federation, which is ideologically opposed to the Chávez government and the Barrio Adentro medical program, filed a lawsuit to prohibit Cuban doctors from practicing medicine there. The court held in favor of the Medical Federation, but the Venezuelan government did not back down.

Similarly, in Bolivia, when the Colegio Médico de Bolivia and the association of unemployed doctors went out on strike to protest the presence of the Cuban doctors, President Evo Morales asserted publicly that the Cubans would stay as long as he is in office. He also exhorted the Colegio Médico to change its attitude and to ?pay? with their professional services for their free medical education in public universities paid for by Bolivian taxpayers. Like in the case of Venezuela, the benefits to the host society far outweigh the costs to the local medical professions, which in these two cited cases are ideologically opposed to the government.

At the urging of the Haitian medical association, the previous government asked for a revision of the cooperation agreement to include better control by the Ministry of Health over the mix and quality of medical staff sent as well as the nature of their work in the field. However, this revision has yet to take place. Some malpractice accusations have been made against Cuban doctors in Venezuela, South Africa, Zimbabwe, and Haiti. A much-publicized case in Venezuela proved to be the fault of opposition doctors who refused to treat a patient referred to a hospital by a Cuban doctor. On the other hand, it is quite possible and, indeed, probable that there are some genuine cases that need to be addressed. This would be normal among all cohorts of practitioners and should be properly investigated and remedied.

Rewards For Medical Diplomacy

As stated at the outset of this article, Cuba?s rewards are symbolic and material capital. There is enormous prestige and influence in determining the direction of public health systems in the countries in which Cuba practices medical diplomacy. The training of future leaders in the medical field assures Cuba of on-site support in the future. More importantly, Cuba?s medical diplomacy contributes to the positive views held by other governments as translated into voting results at the United Nations on issues of particular importance to Cuba, such as an end to the US embargo of Cuba and the stressing of human rights issues. Importantly, Cuba was elected to the new UN Human Rights Council by direct, secret ballot in which all member states were elected individually and not in blocs.

In a press conference reported in the daily Última Hora, Paraguayan President Nicanor Duarte Frutos explained why his country would abstain rather than vote in favor of the US sponsored anti-Cuba resolution at the UN Human Rights Commission in Geneva, despite President Bush?s personal call in April 2004 asking for his support. The reason: a cooperation agreement with Cuba dating back more than six years, whereby Cuban doctors provide medical assistance in Paraguay and Paraguayan youths from very poor families are studying in Cuba on scholarships. At that time, there were 600 students involved in the program.

With regard to the US embargo of Cuba, the US State Department?s own data show that in the 2005 General Assembly votes, only Israel, the Marshall Islands and Palau supported the US position. This was the fourteenth consecutive time in which the US position was rejected, but to no material benefit to Cuba since the US has been going it alone for a long time now on this issue. Among Cuba?s trade and aid partners, voting coincidence with the US generally ranked only between 6 and 22 percent during 2005. The overall average coincidence for all countries was only 25%. The LAC average was 19.7%. The Asian group average was 18.7%; the African group averaged 13.5%; the Eastern European group averaged 40.4%; and the Western European and Others (Australia, New Zealand) came in at 46.7%. Cuba?s medical diplomacy should be seen as contributing to this pattern. Rather than isolating Cuba, it is the US that is becoming more isolated on this issue.

Far from being marginalized by Washington?s anti-Havana offensive, Cuba has remained an important member of the Non-Aligned Movement and once again has just hosted the summit of heads of state and government in September and has become the leader of the NAM for the next several years. Cuba previously hosted and led the NAM in 1979. Also Fidel attended the July 2006 MERCOSUR summit, which opened with the signing of a trade agreement with Cuba for mutual preferential market access. The agreement consolidates the already existing bilateral agreements on preferential tariffs that Cuba has had with each of the MERCOSUR members. Although the amount of trade between Cuba and MERCOSUR is not great, the agreement is significant for its timing: just before the release of the US-sponsored Commission for a Free Cuba?s tough report on tightening the US embargo and promoting regime change.

More importantly from an immediate standpoint are the export earnings deriving from medical diplomacy. Data on the amount paid for the various activities involved in Cuban medical diplomacy has always been difficult to establish. Rates paid for doctors have ranged from nothing where the country could not afford to pay, to some rate well below market prices. Nonetheless, rough estimates suggest that the amounts are truly significant and have surpassed earnings from tourism. The Economist Intelligence Unit estimates that the increase in non-tourism services exports between 2003 and 2005 was around US$1.2 billion for a total of US$2.4 billion, which puts non-tourism services ahead of gross tourism earnings (of US$2.3 billion) in 2005. Most of this is medical services.

Official data for export earnings from medical products (medicines and equipment) were below US$100 million in 2004, but there have been press reports citing a figure of US$300 million for such products. Cuba exports medical biotechnology products to 40 countries, but sales data were not available. Two important earnings streams not included in the export data come from the licensed manufacture of Cuban medicines in other countries and joint-venture production facilities abroad. Officials in Havana have indicated that these are significant, but no concrete data is available. Cuba has some licensing agreements, including one in the US for anti-cancer drugs, and even joint venture production facilities in China. Also, treatment facilities are being built in other countries, particularly in the field of ophthalmology, under agreement with Venezuela. The oil-for-doctors agreement is very lucrative for Cuba because of preferential pricing for Cuba?s professional services exports and because Venezuela absorbs the loss for any escalation of oil prices, a factor that has occurred to a considerable degree in recent months. Commercial trade between Venezuela and Cuba surpassed US$ 2.4 billion in 2005 and US$1.2 billon in the first trimester of 2006. Also, on the aid side between 2002 and 2006, Cuba has received some US$50 million for a range of physical development programs from the Organization of Petroleum Exporting Countries Fund. These rewards make medical diplomacy well worth the effort, not to also mention the important humanitarian benefits.