Four months after the surprise announcement of his determination to normalize relations with Cuba, President Barack Obama is rapidly translating that wish into reality, with the cooperation of Cuban counterparts and widespread support among Americans. On April 11, the Summit of the Americas featured the first meeting of the two countries’ presidents in over fifty years. Three days later, even amidst a struggle with Congress over a possible nuclear deal with Iran, the Obama administration announced it will remove Cuba from the U.S. list of state sponsors of terrorism, a step Carl Meacham, Director of the Center for Strategic and International Studies' (CSIS) Americas Program, calls “the biggest signal yet that Washington no longer sees Havana as an enemy.”
Authority to lift the U.S. trade embargo of course ultimately remains in the hands of Congress; hence, realistically the full restoration of relations may be slow in coming. Nonetheless, multiple factors steadily propel these bold moves by U.S. and Cuban leaders. As the Cold War becomes more distant and the decades-long failure of U.S. sanctions becomes ever more conspicuous, American public sentiment is softening, and a majority of Cuba’s 11 million citizens yearn for a better life. The opportunity looms for Barack Obama and Raúl Castro to end their respective tenures with a dramatic, historic rebalance, however bumpy and fitful it may be.
Health Collaboration: Opportunities, But Also Challenges
In the unfolding reinvention of the U.S.-Cuban relationship, health appears as a sector with special promise for cooperation, particularly well-positioned to be the front edge of an opening with Cuba. Normalization of relations has the potential for fruitful, enlarged engagement in four key health-related areas that can bring mutual gain in improving lives and advancing knowledge:
- long-range research and scientific partnerships in biotechnology, vaccines, and tropical medicine, involving universities and government institutions such as National Institutes of Health (NIH) and Centers for Disease Control (CDC) on the U.S. side and the Carlos Finlay and Pedro Kourí institutes, the Center for Genetic Engineering and Biotechnology (CIGB), and the Center for Molecular Immunology (CIM) on the Cuban side;
- U.S. private sector engagement to modernize Cuba's system and build capacity, in partnership with both public and hopefully rising private sector Cuban interests;
- lessons from Cuba in preventive medicine and primary care in resource-constrained settings;
- and active U.S.-Cuban collaborations in responding both to overseas health emergencies and to burgeoning demands in low-income countries for assistance in building affordable and accountable basic health services.
We've recently seen intriguing, almost spontaneous tacit partnerships, including Cuban doctors and nurses staffing a USAID-funded Ebola treatment unit in Monrovia, Liberia, in the heat of the near runaway Ebola crisis in the fall of 2014. Realistically, however, systematic openings in health across the areas of highest opportunity will not happen sui generis. They will likely only emerge through determined careful planning and high-level political will, building trust and confidence on both sides – we suggest one concrete way to begin this process below.
Conscious efforts will be needed to insulate health cooperation from broadside partisan attacks on the Obama administration’s efforts to normalize relations, fueled by the onset of the presidential primary season. Deliberate action will be essential to assuage fears of U.S. dominance, especially in how the U.S. private sector shapes Cuba's health system, with respect to equity and access. The U.S. private sector, at risk of a backlash from diehard American opponents of restored relations, will need confidence that it is advisable to enter Cuba seriously. U.S. public resources to stimulate partnerships will be critical, despite constrained U.S. budgets and continued partisan divisions over normalization.
These are but the most obvious of the many complex sensitivities that will have to be navigated. But with luck and political determination, the special opportunities in the health arena will be pursued as attention turns to how, exactly, the new opening in U.S.-Cuban relations is to be seized.
The Two Sides Of Cuban Health Care: High-Quality Primary Care …
These opportunities grow out of a special legacy in health care that spans the history of revolutionary Cuba. Free and universal health coverage, with high-quality primary care, has been fundamental to the Castro government’s legitimacy since its first years. It is a true entitlement, expected by the Cuban people, a positive right enshrined quite simply in Cuba’s 1976 Constitution: “Everyone has the right to health protection and care. The State guarantees this right.”
What started in the 1960s with a 750-doctor Rural Medical Service has grown into a network of more than 30,000 family doctors; across the country, each of five hundred “polyclinics” serves as a hub for twenty to forty neighborhood medical stations. After visiting Cuba in fall 2014, cardiovascular surgeon and former Senate Majority Leader Bill Frist documented impressive primary care:
Patients are seen at least once a year, often in their home[.] Emergencies are addressed immediately. Chronic conditions are identified and managed early.
And this care is provided at no cost. In private conversation with one of the authors, Frist subsequently marveled that not only does the average individual Cuban have a primary physician, that person knows his or her physician by name. That is a fading reality in America, true for only a minority.
… But Big Gaps In Technology
The other reality of this extensive health system, however, is a gaping hole in capital-intensive, technologically advanced areas of medicine. Cuban physicians, described by Frist, “may not have a nurse, an x-ray machine or access to the internet.” In the Special Period of the early 1990s, with the loss of Soviet assistance, Cuban spending on public health dropped a staggering 70 percent, and the government concentrated what remained into primary care at the expense of hospital medicine; meanwhile, the American trade embargo aggravated shortages in medical supplies. Legislation signed by President Clinton in 2000 created an exception in the embargo for medical supplies and devices, but shortfalls continue. As Senator Frist writes, “There are shortages of medicine, imaging equipment, operating rooms, and essential cancer treatments.” He concludes: “You do not want to be seriously ill in Cuba.”
The Global Legacy Of Cuban Health Care
The Cuban government’s long history in health extends overseas. In 1963 Cuba dispatched fifty doctors and nurses to Algeria, which had recently won its independence from France. Two years later, as told in the political science study Cuban Medical Internationalism, Che Guevara led an ill-fated mission of 200 guerrillas to Congo that included a medical contingent and 61,000 doses of polio vaccine. Over the next fifty years, as CSIS Senior Associate Katherine Bliss summarizes a 2011 seminar, Cuban doctors worked in “more than 100 countries, including those with which Cuba does not have official relations, or with which the relationship is strained.” In late 2014, more than 250 members of Cuba’s Henry Reeve Medical Brigade—named for an American who died fighting for Cuba’s independence from Spain—staffed Ebola treatment units in Liberia and Sierra Leone.
This five-decade campaign of global health assistance has served two primary purposes. First, it is a soft power tool that, at various times, has branded Cuban foreign policy as humanitarian, advertised Cuban-style socialism, and helped an island nation ninety miles off the coast of an enemy superpower win friends and punch above its weight internationally. Julie Feinsilver has written that Cuban medical diplomacy “garnered symbolic capital (prestige, good will, and influence) for this small, developing country way beyond what otherwise would have been possible and has helped cement Cuba’s role as a player on the world stage.”
Second, Cuban medical expertise has been a commodity to barter for much-needed foreign currency and energy supplies. When thousands of Cuban troops were deployed in the 1980s to Angola and Ethiopia, financed by the Soviets and compensated with Angolan oil, hundreds of Cuban health workers were dispatched as well. In more recent years, as described by Katherine Bliss, Venezuela under Hugo Chávez “provided oil at an affordable price to the cash-strapped Cuban government in exchange for 3,000 primary care doctors” and hundreds of new health clinics and physical therapy centers.
Given Chávez’s death in 2013 and Venezuela’s pressing budget concerns in the face of falling oil prices, however, this era in Cuban-Venezuelan relations may be closing. Meanwhile Brazil, having received 11,000 Cuban doctors, has emerged as a top supplier of agricultural assistance to Cuba and is leading the $900 million upgrade of Cuba’s deep-water Mariel port. These developments have seen controversy among Brazilians who question Cuban doctors’ qualifications and who resent the parallels to Venezuela. Finally, in addition to dispatching doctors abroad, Cuba generates revenue at home by training foreign medical students. Though Cuba’s Latin American School of Medicine (ELAM) is rightly known for its generous scholarships, many foreign students pay full freight, precious foreign exchange provided by their governments – Kenya, Chad, South Africa, among others.
Finding Ways To Realize Mutual Gain
With its track record of quality primary care in highly constrained environments domestic and international, Cuba has acquired decades of experience in sustainable, cost-effective health systems in low- and middle-income countries. At home and abroad, Cuba has also acquired significant expertise in natural disaster response. These are of inherent value to U.S. global health programs and relief efforts in emergency settings. Cuba’s success in monitoring and addressing lifestyle risks early sets a model for U.S. primary care and preventive medicine in resource-constrained settings; already, a number of ELAM graduates serve in low-income areas of the United States. Likewise, the prospect of U.S. private-sector medical technology is of innate value to Havana policymakers concerned with the systemic, worsening gaps in Cuban hospitals and tertiary care. Cuba’s strong foundation in biomedical research makes collaboration with NIH-supported scientists highly appealing as well. Organizations like Medical Education Cooperation with Cuba (MEDICC) have already been working for some time to promote U.S.-Cuban health cooperation and the mutual gain it generates.
Still, U.S. firms and researchers are wary of making serious commitments while the embargo remains in place. No matter how inexorable the changes in U.S.-Cuban relations, President Obama, a second-term president without Congressional support, will struggle to provide the predictability necessary to long-term agreements and substantial investments. Serious concerns persist that the normalization of relations neither reinforce the power of an authoritarian, military-dominated Cuban state which controls key sectors of the economy, including health, nor sanction continued abuses of civil rights. On the Cuban side are concerns about too much U.S. control and longstanding caution about rapid change, liberalization, and the possibly corrupting influence of U.S. corporate, market-style health care. Lurking on both sides are inescapable budget constraints, with the United States in an era of continuing resolutions and sequestration, and Cuba, nearly a quarter century after the fall of the Soviet Union, finding its way with less Venezuelan support.
Thus far, health has not figured prominently in the Obama-Castro reset, which is hardly surprising in these early days, focused as the parties are on unshackling the relationship from decades of strategic confrontation and deep estrangement. In the months and years to come, however, leaders on both sides will need to consciously elevate health as a priority, if they are to transcend the many barriers and jumpstart partnerships.
A Proposal To Begin Moving Forward
Animated by shared interests, health has long been a non-political vehicle for collaboration, helping advance even the most sensitive international relationships. In the 1970s, Nixon and Brezhnev found common ground in cooperation on cancer, environmental health, and infectious diseases. Today, amidst a changing security relationship and drawing on twin legacies in global health and disaster response, medical research and health cooperation can be the front edge of a new U.S.-Cuban relationship. But unlike the spontaneous day-to-day collaboration spurred by emergency conditions in Liberia, sustained cooperation will arise only through high-level political will that deliberately protects the health sector from our own partisan politics and electoral processes.
To signal intent early, and get things moving, the United States and Cuba should now jointly establish an exploratory committee charged with setting out a clear path for future health collaborations. Important Republican opinion leaders like Bill Frist should be among the first experts called upon to advise it.
Editor's Note: This article has been updated to correct minor errors in the original version.