By Gail Reed

In the fall of 1998, Hurricanes Georges and Mitch ripped through the Caribbean and Central America, leaving 30,000 dead or missing, and 2.4 million homeless. Regional leaders appealed for help, and Cuba offered to send 2,000 doctors to the stricken zones. They were on the ground within days in Honduras, Nicaragua, and Belize, setting up makeshift hospitals and working by kerosene lamp. But when the flood waters cleared, they were forced to confront what President Fidel Castro termed “a hurricane worse than Mitch:” millions of people without health care, millions whose first contact with a health professional came after the storm.

While Cuba’s international medical service goes back to 1960 in Chile (its first disaster relief aid) and 1963 in newly independent Algeria (its first long-term assistance), and the Third World has many thousands of doctors who graduated in Cuba, never before had the Cuban government developed an integral approach to service and education that prescribed sustainability as a primary goal. This would become the Comprehensive Health Program (CHP), begun in 1998 for Central America and the Caribbean, and later extended to South America, Africa and Asia.

Drs. Noel Marzo and Leysi Palacio in Nawlero, Gambia, with their patients and the donkey cart that takes the doctors for drinking water several kilometers away.

Under the CHP, government-to-government accords deploy Cuban health care professionals for remote and under-served populations in each country, mainly family doctors; and Cuba also offers 6-year medical school scholarships to young people from these same areas to study at the Latin American Medical School (see Cuban Med Schools Open with Record Enrollment this issue). The hope is that the graduates will return home to replace the Cuban physicians. Hence, sustainability.

But while the long-term goals of the program are yet to be tested - the Latin American Medical School graduates its first physicians in 2005 - the shorter term contribution to the health picture in each country is undeniable. Since its beginning, 8,168 health professionals have served abroad under the CHP, and currently 2,778 (78% of them physicians) are working in 24 countries, their health coverage extending to 58.6 million people. Table 1 illustrates how this has translated into increased patient care for poor communities in Africa, the Americas and Asia.

Under the bilateral agreements, the host country provides accommodations and basic foodstuffs, domestic transportation, a locale for work, and a monthly stipend (US$100-$200), while Cuban personnel receive their regular salaries and other logistical support from the Cuban Ministry of Public Health.

Notes: “Doctor’s Visits” are patients’ visits to the doctors’ offices; housecalls are home visits. “Surgeries” includes both major and minor surgeries.

Source: Comprehensive Health Care Program, MINREX, Havana, September, 2004.

The health picture has also improved: in areas where Cuban doctors serve in Guatemala, the infant mortality rate has dropped from 45 to 16.8 deaths per 1,000 live births; in Gambia, from 121 to 61; in Haiti from 59.4 to 33. Maternal mortality in these zones has also dropped significantly (see Figure 1 below).

Figure 1: Maternal Mortality Rates in Zones Served by Cuban Medical Teams (1999-2003)

Source: Country reports from Cuban medical teams, Unidad de Colaboración Médica, Ministry of Public Health, Havana, 2003.

The aim of Cuban assistance has been to bolster public health infrastructures, providing the often desperately needed staff in remote areas, where authorities have been unsuccessful in attracting local physicians to the public sector. In countries like Honduras, Haiti, Guatemala, Mali and Gambia, Cuban physicians have been the first bearers of health services to rural, indigenous and other marginalized communities. They also take the Cuban ethic of service and philosophy of combining prevention with clinical medicine - carrying out some 11.3 million health promotion and education activities since 1998.Cuban medical scientists and advisors have also participated in design of public health departments and systems, and in epidemiological research and campaigns tackling specific health problems (malaria in Gambia and several other African countries, dengue fever in El Salvador and Honduras, HIV-AIDS in Mali and Haiti). And they are working with health ministries to develop more reliable statistical record-keeping in various countries, especially in those with the weakest infrastructures.

Recently, Cuba has initiated trilateral partnerships, in which a third country or agency donates resources for health programs pacted between Cuba and another nation. This was the case of the 2001-2002 vaccination drive in Haiti, when Cuban epidemiologists and family doctors teamed up with Haitian health authorities to vaccinate children against five childhood diseases, with vaccines provided by the French and Japanese governments. The South African government donated US$1 million for Cuban medical cooperation with Mali; and the WHO and PAHO have supported the Latin American Medical School and Cuban collaboration in Gambia. According to the Cuban government, 95 non-governmental organizations worldwide have contributed to CHP projects since 1999.

Cuba’s South-South cooperation has faced endless challenges: the instability besetting many developing countries; the sheer size of the effort and resources needed to make a dent in the poorest countries’ health status; barriers to access and treatment found in the various health systems staffed by Cubans; initial concerns from in-country medical associations fearful of job displacement; the need to expand the skill set of Cuban physicians serving abroad, who confront circumstances and infectious diseases long absent from the Cuban health picture; and the abiding question of whether a majority of the thousands of foreign students who graduate from Cuban medical schools will actually return home, have jobs and make a difference.

But some truths already speak for themselves: while Cuba’s financial resources are limited, its human resources are legion, and the country has shared both generously - deploying more health professionals abroad than the entire United Nations system and providing more scholarships in medicine than any other country in the world. Perhaps a call for others to step up to the plate.