Dispatches: Cuba's Medical Missions

Alejandro Tarre on the other side of Cuba's overseas medical missions. (slideshow available)

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Cuban doctors
Cuban health workers unload medical supplies in Sierra Leone in October 2014. Photo: Florian Plaucheur/AFP/Getty

Dispatches: The Stethoscope Diaspora

Alejandro Tarre

Alvin Mena Cantero might seem indistinguishable from the thousands of hard-working Cuban immigrants in Houston. The 30-year-old recently bought a house in the suburbs and has two jobs, one as a family nurse and the other as weekend supervisor at a mental health center. But Mena is no ordinary exile.

Just four years earlier, he was among the tens of thousands of Cuban health professionals deployed to Venezuela under a bilateral aid-for-oil agreement initiated in 2003. He graduated at the top of his class from Calixto García University Hospital in Havana and was selected to serve in the medical mission in Venezuela.

Mena left the island knowing he was not coming back. He was convinced that doctors in Cuba could not make a decent living. He planned to work for six months in Venezuela, save money and then leave the mission to start a new life in another country.

View a slideshow of Mena's life in Cuba and the United States here.

But things did not go according to plan. When he arrived to Venezuela, he was posted in Yumarito community in the western state of Yaracuy. Poor working and living conditions and harassment by his supervisors soon became unbearable, Mena says. Just a month after he arrived, he abandoned his post and took a bus to Caracas.

He went to the U.S. Embassy and submitted an application for a visa under the Cuban Medical Professional Parole Program, a program targeted to Cuban health professionals stationed abroad. Within a matter of days, he received the visa and a sealed envelope to give immigration officials once he arrived in the United States. Mena immediately bought a plane ticket and sent his travel information to his contacts at Solidaridad Sin Fronteras (Solidarity Without Borders), a Miami-based ngo that assists immigrant doctors in the United States. At dawn on December 31, 2009, Mena, then 26, arrived at Maiquetía Airport outside Caracas to board a flight to Miami.

That’s when things started to unravel. Mena had assumed the visa would shield him from scrutiny by Venezuelan authorities. But when he admitted that he worked in one of the Cuban health missions, a young immigration official called him a “traitor” and ordered him into a security office at the airport, where another official took away his ticket, ripped up his passport and threatened to deport him to Cuba.

The official even took pictures of Mena with his cell phone and delivered a curt warning: “If you escape, these will be circulating all over Venezuela.” At some point, Mena managed to send a text message to his contacts at Solidaridad Sin Fronteras. “This is the end of the road for me,” he recalls writing in despair.

Mena’s story highlights the plight of many Cuban exiles who made similar journeys, but it also raises some questions about one of Havana’s most admired soft power initiatives.

The Cuban government says it has deployed more than 270,000 health workers abroad between 1961 and 2008.1 In recent years, Cuba has acted as a first responder to international crises. It rushed doctors to Pakistan in 2005 after the earthquake there. In 2010, Cuban doctors were the first on the scene after a similarly catastrophic earthquake in Haiti.2

In autumn 2014, Cuba sent nearly 500 health professionals to fight Ebola in West Africa,3 prompting thanks from Margaret Chan, the director-general of the World Health Organization (WHO), and David Nabarro, the “Ebola czar” for the United Nations,4  as well as praise from World Bank President Jim Yong Kim, U.S. Secretary of State John Kerry, and U.S. Ambassador to the UN Samantha Power.5

Medical missions, though, are more than charity. Host governments pay a fee for the health workers, only part of which is used to cover their expenses and salaries. The bulk of the money goes to the Cuban government.6

Dagmar González Grau, director general of the Cuban Ministry of Foreign Trade and Investment, said last July that the country’s export of health services generates an annual income of about $6 billion.7

“It’s the main source of revenue for the economy,” says María Werlau, founder of the nonprofit Free Society Project and an expert on Cuba’s health services export industry. “No other sector, including tourism, makes more money.”8

For years, however, these missions have served as a quiet escape route for disaffected Cubans. In 2013 alone, more than 3,000 doctors defected under the U.S. visa parole program.9

Stéphanie Panichelli-Batalla, a lecturer in Spanish and Latin American Studies at Aston University in Birmingham, U.K., has been compiling testimonies of health workers who have served in Cuban international medical missions. She says that in some countries, doctors describe their experience as slavery, while in others, they have very few complaints. Still, the picture that emerges from the testimonies is grim.

In Venezuela, for example, health workers can be forced to work long hours and live in shabby, overcrowded quarters devoid of privacy. They generally lack freedom to move and face constant surveillance.10

Under a policy meant to prevent defections, doctors must leave their families in Cuba and use a passport that may not bear visas from countries other than their work destination.11 They often receive part of their salaries when they return to Cuba. Defectors risk being labeled traitors and sent home if they’re caught.12 Some health workers worry that they will expose their families in Cuba to reprisals if they defect.13

Mena did not stay long in the Venezuela mission, but he says he was a victim of some of these abuses. He lived in a small, humid room with leaks in the ceiling and no running water. He had no air conditioner and hardly a day passed without a blackout. His supervisors often forced him to work overtime without additional pay and if he was invited for dinner with locals, he had to ask for permission.

On several occasions, his supervisor told him to praise then-President Hugo Chávez’ social policies in front of his patients. He was paid just $140 for a month of work. The government was supposed to deposit another $80 in his bank account in Cuba, but Mena says he had no reason to believe he would ever receive that money after he defected.

The conditions faced by Cuban doctors abroad have started to attract greater scrutiny. Since late 2013, Brazil has contracted about 14,000 foreign health workers—the vast majority of them Cuban—to work for Mais Médicos (More Doctors), a program that deploys medical personnel to remote areas where local doctors are scarce.14

Agreements differ by country, but under the terms of the agreement between Cuba and Brazil, the Brazilian government pays the Pan American Health Organization (PAHO), a branch of the who, for the Cuban health workers’ services at a rate of 10,000 Brazilian reais a month per worker—about $4,300 when the program started.15 PAHO in turn pays the Cuban government after taking a 5 percent administrative commission.16 Yet Cuban health workers in Brazil earned roughly $1,000—later raised to around $1,200—reportedly four times less than what doctors from other countries earn working for Mais Médicos.17

Last November, while Cuba was being hailed for its Ebola relief program, a Brazilian federal prosecutor, Luciana Loureiro Oliveira, urged President Dilma Rousseff’s administration to pay the Cuban doctors directly, calling the agreement “frankly illegal.”18

The salary Cuban doctors earn in Brazil, however, is generous compared to what their counterparts in Venezuela earn.

Julio César Alfonso, president of Solidaridad Sin Fronteras, says Cuban health workers in Venezuela—where Cuba deploys the majority of its international medical work force19—earn between $250 and $300 a month. But according to a 2011 agreement, Venezuela paid Cuba more than $10,000 a month for every doctor—far more than Brazil pays.20

Alfonso says that doctors participate in missions under such conditions mainly for economic reasons. Even though the Cuban government pays doctors only a fraction of what it receives from host countries, this fraction still far exceeds what Cuban doctors earn at home—about $60 a month after a raise last year.21

But economic incentives are not the only factors that drive Cuban doctors abroad.

Although participation in the overseas programs is ostensibly voluntary, a refusal to accept a recruiter’s offer “would mark you as unreliable,” says Alfonso. “That would completely limit your professional development.”

As in Mena’s case, finding a way to escape Cuba is another incentive. Panichelli-Batalla says she has heard of cases of Cuban doctors who chose to study medicine in order to be able to work abroad, which, in turn, would give them an opportunity to escape the island.

That was not Mena’s motivation. He wanted to be a doctor since he was a teenager. But soon after he began his medical studies, he decided to leave Cuba. “That became my sole objective,” he says.

And eventually he achieved it, despite the incident at Maiquetía Airport. Five or six hours after his detention at the immigration checkpoint, Mena was released by a young security guard after Mena’s uncle showed up at the airport with a lawyer to pressure the authorities. Mena isn’t sure whether his uncle’s intervention made a difference, or whether a sympathetic guard just looked the other way.

The young doctor wasted no time. A friend of his uncle took him from the airport to Caracas’ main bus terminal, where he bought a ticket to San Cristóbal near the border with Colombia. During the trip, which lasted about ten hours, Mena was hungry and disoriented. Still feeling unsafe, he wondered whether the official had made good on his promise to circulate his picture.

On the first evening of the New Year, he arrived in San Cristóbal. He no longer had his passport, but he still had the sealed envelope the U.S. Embassy had given him—he never discovered what it contained—along with his visa.

On January 4, Mena crossed the border to Cúcuta in Colombia, pretending to be a local gas smuggler, and then boarded a bus to Bogotá, where he went to the U.S. Embassy. Two weeks after he had stolen away from Caracas airport, he finally landed in Miami.

In the beginning, life in the U.S. was not easy. He moved to Houston on the advice of other doctors, who told him the city offered many opportunities for health workers. But Mena barely spoke English and had no friends. For six months, he worked as a bartender and as a medical assistant.

After he learned the language, he enrolled in school and obtained a nursing license. Soon he was able to land better jobs, earn more money and even attend graduate school.

Last year, after he bought his house, Mena applied for citizenship with the intention of bringing his family, now in Cuba, to live with him. He is planning to enroll in a PhD program on mental care and plans to open a private practice, which he hopes will include a mobile unit to assist people in low-income areas without access to healthcare.

In one of our conversations, I observed he was planning to do exactly what the Cuban government sent him to do in Venezuela.

“I agree it’s important to provide health services to people without access to them,” he responded. “The problem with Cuban medical diplomacy is not that it targets people in need, but the fact that it exploits and mistreats doctors.”

Endnotes

All images courtesy of Alvin Mena Cantero.