Cuba is a global provider of health services, or, as a BBC report phrased it, ‘healthcare is Cuba’s most lucrative export’. Whatever humanitarian impulses lie beneath it, these programmes represent a multi-billion dollar money-spinner for Cuba.
This is all well and good, and not to be judged too harshly since development cooperation invariably comes with some self-interest in mind. But the programme has a highly controversial side. While a comprehensive picture of the inner workings of these programmes is elusive – given both the authoritarian nature of Cuba, and the fact that the on-the-ground operation of the medical work would be governed at least in part by bureaucratic rules that would differ from place to place – enough has come to light to raise serious questions.
Cuba retains a tight rein on participants in the programme. This was laid out in investigations by the Spain-based rights group Prisoners Defenders among Cuban doctors who had participated in these programmes and subsequently defected. Many prospective participants felt pressured into signing up, and most had no advance knowledge of where they were to be posted. One in four had their passports taken by the Cuban authorities once they arrived at their destination and nine in ten reported being monitored by Cuban security officers – and also required to report on their colleagues.
Doctors would not be able to have their families accompany them on long-duration postings, giving the state an enormous degree of leverage over them. Misbehaviour or displeasing their government (or defecting) could have serious ramifications for loved ones.
An even darker side has emerged in reports out of Venezuela. Cuban doctors were brought in to service poorer areas by the then petrocash-flush regime of Hugo Chavez in the early 2000s. As these funds have dried up and the economic folly of the past years has become ever more dire – and as the personally charismatic Chavez was replaced by Nicolas Maduro – Venezuela has turned ever more to weaponizing the means of livelihood. In this respect, Cuban doctors have reported being told not only to promote political support for the government, but to use access to medical care and equipment as a reward for its supporters and their denial as a punishment for opponents.
Less than idealism, this is the orientation of the venal ideologue.
Then there is the money. There have also been allegations that doctors are instructed by their Cuban superiors to falsify reports about their patient numbers and the treatment given so as to inflate the perception of effectiveness. This makes the case for expanding the programme.
But one of the most visible concerns is that the Cuban doctors who actually render the services are short-changed. The primary beneficiary of the payments made by host governments are not the doctors, but the Cuban state. This has been highlighted by an ongoing lawsuit in the United States by a number of Cuban doctors who are now living there. Their case, against the Pan American Health Organisation (PAHO), charged that the PAHO benefited from the ‘forced labour’ of thousands of Cuban doctors who worked in Brazil under an agreement which the organisation mediated. Of the $10 000 paid for each doctor – according to this group – the doctor received $1 000 (part of which was paid to accounts in Cuba), and the rest to the Cuban state. The PAHO had received a payment for assisting in the agreement. They also allege that a battery of control measures – such as confiscating passports – was deployed against them.
What this means for South Africa
It is unclear just how these abuses may have been replicated in South Africa. South Africa’s political environment is very different from that in Venezuela, and the geopolitical stakes for Cuba much higher in the Latin American country. The deployment of Cuban doctors on longer-term contracts, well publicised in the 1990s, has also declined significantly (medical cooperation with Cuba has come to be based rather on training doctors in Cuba, which has itself been the subject of intense debate in the medical community). An academic study of the doctors programme, published in 2007 by British researcher Daniel Hammett, indicated that initially families were allowed to accompany participating doctors to the country (although this was later halted), and the doctors were paid according to South African scales. All in all, a fairly benign picture, albeit one complicated by instances of Cuban doctors trying to opt out of the programme and approaching the courts to remain in South Africa. The latter was decidedly inconvenient for South Africa, since it both broke with the ideological narrative, and invoked another deeply ideological commitment for South Africa, labour legislation, in doing so.
I well recall a TV news broadcast in the late 1990s where a black Cuban doctor pleaded to remain in South Africa because he had married a South African woman, which would not be well received by his country’s authorities (it is widely reported that romantic liaisons are forbidden or frowned up for those participating in medical programmes.) ‘I could be killed,’ he said. Maybe there was an element of exaggeration, though I for one hope he got to stay.
In the case of the Henry Reeve Brigade, the question of family accompaniment is moot, since it is a disaster relief institution with a limited-time mandate. (Would a Cuban doctor want to bring spouse and children to South Africa under present circumstances?) Payment is more contentions.
The emergency workers came to South Africa at a reported cost of R430 million, according to a report in News24 in April 2020, which drew on Treasury documents. Later in the year, health minister Zweli Mkhize put the salary bill for the Cuban medics at R239 million.
Whether this salary bill will find its way into the pockets of the medics, or the Cuban state is unclear. Queries have been greeted with a mixture of deflection and indignation. A spokesman for the health department waved away cost concerns: ‘It is not fair that anyone should focus on the price tag over the need to save lives.’ (Such rhetoric has an unfortunate habit of confirming that cost concerns are merited.)
The Cuban embassy appealed in its Facebook page to the noble traditions of solidarity and the malicious machinations of enemies. ‘This is not a commercial transaction. This is cooperation,’ it said, although a strong element of commercialism does run through its medical cooperation.
Incidentally, while medicine is Cuba’s flagship ‘cooperation’ programme, it is not the only one. In a highly controversial endeavour, the military has engaged Cuban technicians to maintain vehicles. This has been criticised for its cost, for servicing machines that should be scrapped and for ignoring the pool of South Africans who might do this work. Pikkie Greef of the SA National Defence Union described the payments to Cuba as effectively a ‘labour brokerage fee’.
Greeff may well be onto something. Describing Cuba’s programmes as ‘slavery’ or ‘forced labour’ may overstate the case. But there is certainly something in what has been alleged about them that comes close to trafficking. In the South African case, it looks remarkably like labour broking. If the state looks disapprovingly at this when it happens in the private sector, it is unconscionable to practise it itself.
Ultimately, commenting on the Cuban Medical Brigade in the Daily Maverick, Rebecca Davis summed up the issues: ‘But the government still has pressing questions to answer: about the price tag of the mission, whether the expertise offered by the Cubans could truly not be replicated locally at a lower cost, and ultimately whether the real beneficiary of the deployment is South Africa, or perhaps the cash-strapped Cuban state.’
Who benefits? This really is the question. The answer is ambiguous. Whatever factors motivate Cuba’s medical diplomacy (and its other cooperation), it is certainly not solely altruism. It generates very real advantages by doing so. A system of mutual aid perhaps?
This is not outlandish. South Africa is a donor of some substance, primarily in Africa, although not exclusively. Cuba itself was a recipient of a R350 million aid package in 2012. Medical and technical services provide a handy means for South Africa to assist an ideological ally with which it has few economic complementarities.
No less an act of aid is the nomination of the Cuban Brigade for the Nobel Peace Prize. This helps frame the Cuban national image and embellish its mystique. It is intended to feed the (rather distorted) narrative of selflessness in the country’s actions and its role in the world. This is key to Cuba’s global positioning. This might be harmless were it not effectively whitewashing the abuses of an authoritarian regime. This is not least against the ‘Cuban people’ so beloved of Cuba’s foreign admirers. ‘Let there be more generosity, more co-operation, and more humanity,’ said Fidel Castro in his address to South Africa’s Parliament. This is wise advice, and should be heeded. Not least in the way Cuba’s friends structure their relations with it. It is past time for a critical appraisal of the Cuban state, and for a clear distinction between the state and its people to be drawn.