The United States’ 21st Century Response to Cuban Medical Internationalism

The United States’ 21st Century Response to Cuban Medical Internationalism Introduction In the period after The Cuban Revolution, medical personnel has emerged as Cuba’s most valuable export. With 50,000 doctors and nurses in over 60 countries, Cuba brings in roughly $10 billion a year and an unquantifiable amount of positive attention from the international community1. Some, however, have claimed that Cuba’s medical internationalism is a form of human trafficking due to low salaries paid to participants that are garnished by the Cuban government and poor treatment in host countries2. In 2006, the United States formalized its support for Cuban doctors who defected from international missions through the Cuban Medical Professional Parole Program (CMPPP) with a promise of an accelerated visa process3. This program was formally ended in 2017 due to improved diplomatic relations between the United States and Cuba under The Obama Administration. Despite this, many still defect from their missions and there have been recent calls by The United States Senate to reintroduce the program. In this paper, I will provide an overview of Cuba’s medical export program, the CMPPP, and the CMPPP’s discontinuation before moving into a discussion on how this has affected Cuban medical professionals globally. I have found that volatility in the United States’ treatment of Cuban medical personnel, and recent ideological changes in Latin American nations such as Brazil, have been politically motivated rather than humanitarian4. If nations are truly 1 Nugent, Ciara. “How Doctors Became Cuba's Biggest Export.” Time. Time, November 30, 2018. Thomson Reuters Foundation. “U.S. Says Cuban Medical Missions Are Trafficking Doctors.”. 3 “Cuban Medical Professional Parole (CMPP) Program.” United States Citizenship and Immigration Services, January 19, 2017. 4 Darlington, Shasta. “Cuba Is Pulling Doctors From Brazil After 'Derogatory' Comments by Bolsonaro.” The New York Times. The New York Times, November 14, 2018. 2 dedicated to ending this “human trafficking”, they need to implement policies that directly address the working conditions and immigration concerns of Cuban personnel. Cuban Medical Internationalism In “Brain Drain Politics: The Cuban Medical Professional Program”, author H. Michael Erisman argues that Cuba’s medical aid programs are more extensive than any nation or internal organization in the world5. According to Erisman, Cuba sent over 134,000 doctors and nurses abroad between 1961 and 2009 to over 107 countries. It is important to note that this number, reported by Erisman and supported by Cuba Sí, is much less than the 400,000-figure touted by the Cuban Communist Party6. Cuba focuses its medical exports, which also include education and facility-building assistance, on areas “where no local doctor would work”7. Between 1961, when Cuba sent its first mission to Chile, and 2009, Cuban doctors have treated roughly 130 million patients8. This has brought revenue in for the Cuban government in the form of garnished wages from doctors, but also through the biotechnology industry that saw $350 million in sales in 2008. Salaries paid to doctors who go on missions abroad tend to be much higher than salaries within Cuba. One doctor reports making $250 per month in Venezuela while Cuban doctors were making only $15 a month9. However, medical personnel on missions are permitted to keep only 10-25% of their wages, sending the rest back to the Cuban government10. 5 Erisman, H. Michael. "Brain Drain Politics: The Cuban Medical Professional Parole Programme." International Journal of Cuban Studies 4, no. 3/4 (2012): 269-90. Accessed April 30, 2020. www.jstor.org/stable/41946012. 6 Herrera, Leydis Maria Labrador. “#CubaSalva: Práctica Humanista De La Revolución.” Granma.cu, March 23, 2020. 7 Feinsilver, Julie M. "Fifty Years of Cuba's Medical Diplomacy: From Idealism to Pragmatism." Cuban Studies 41 (2010): 85-104. Accessed April 30, 2020. www.jstor.org/stable/24487229. 8 Ibid. “Brain Drain Politics: The Cuban Medical Professional Parole Programme”. 9 “The Hidden World of the Doctors Cuba Sends Overseas.” BBC News. BBC, May 14, 2019. 10 Ibid. “The Hidden World of the Doctors Cuba Sends Overseas.” Some have called Cuba’s medical personnel an “army of white coats” due to the international power and reputation they have granted Cuba. The Pan American Health Organization (PAHO), a division of the World Health Organization, granted Cuba with a prestigious public health award in 201711 and Cuba has received acclaim from the United Nations that undermines historical attempts of isolation by the United States12. Through medical exports, Cuba has formed an “Oil for Doctors” program with Venezuela13, received a $150 million line of credit from Russia14, and gained positive media coverage during the 2014 Ebola outbreak. The Henry Reeve Emergency Medical Contingent, created by Fidel Castro in 2005 has been sent to 21 countries after disasters such as floods, which again positions Cuba as a benevolent nation and creates important diplomatic ties15. The Reeve Contingent is particularly important for Cuba’s international image, as their benevolent response both puts them at the forefront of the concussion surrounding disasters and forms key relationships with countries in their times of need. There are some serious concerns about Cuba’s medical internationalism. In addition to the 75-90% of doctors’ wages being garnished by the Cuban doctor, nearly all of the rest is frozen in Cuban bank accounts that cannot be accessed until the mission is complete16. These wages are often much lower than those paid by the WHO or paid to native doctors in host nations 11 Mitchell, Cristina. “Cuba's Henry Reeve International Medical Brigade Receives Prestigious Award.” Pan American Health Organization / World Health Organization, May 26, 2017. 12 Hurley, Gail. “Cuba's Strong Tradition of Medical Internationalism Looks Set to Continue despite Upheaval in the Americas.” LSE Latin America and Caribbean. London School of Economics, April 9, 2020. 13 Ibid. “Cuba's Strong Tradition of Medical Internationalism Looks Set to Continue despite Upheaval in the Americas.” 14 Ibid. “Fifty Years of Cuba's Medical Diplomacy: From Idealism to Pragmatism.” 15 Petkova, Mariya. “Cuba Has a History of Sending Medical Teams to Nations in Crisis.” Latin America | Al Jazeera. Al Jazeera, April 1, 2020. 16 Herrera, Leydis Maria Labrador. “#CubaSalva: Práctica Humanista De La Revolución.” Granma.cu, March 23, 2020. and Cuban doctors abroad have no right to organize for better wages or freedom of travel17. As mentioned earlier, Cuba’s doctors are sent to extremely poor regions of nations like Zimbabwe18 and Venezuela where they are unable to work properly or have a decent standard of living19. Misael Hernández, a Cuban doctor formerly stationed in Venezuela, alleges that participants in the program are expected to fake the numbers of patients they are treating to boost numbers that the Cuban government can report. A combination of these issues has led to claims by the United States, Brazil, and Cuban doctors themselves that the medical export program is a form of slave labor or human trafficking. A 2019 Resolution by Senators Bob Menendez (D-NJ) and Marco Rubio (R-FL) asserts that the program constitutes human trafficking due to the withholding of Cuban passports and restrictions on doctors’ right to move, retaliation towards families of defectors, and threats of exile to doctors who do not completely adhere to Cuba’s restrictions20. PAHO has come under fire for enabling this “trafficking” due to a contract with the Brazilian government that resulted in Cuban workers being paid less than 10% of what the Brazilian government paid PAHO, with Cuba’s government receiving 85% and PAHO pocketing 5% of the fees21. Defection rates are difficult to estimate, but roughly 1,800 doctors out of 9,000 remained in Brazil after being called back to Cuba when President Jair Bolsonaro called the program “slave labor”22. The Cuban Government 17 Torres, Nora Gámez. “Cuban Doctors Get a New Shot at Emigration - If Applications Were Submitted Prior to Cutoff.” Miami Herald, January 19, 2017. 18 Garcia, Sandra Marquez. “Cuba News / Noticias - CubaNet News.” Inicio Cubanet, June 6, 2000. 19 Pentón, Mario J. “Cuban Physicians Still Abandoning Missions Abroad despite End to U.S. Parole Program.” Miami Herald, March 12, 2018. 20 Menendez, Robert, and Marco Rubio. “Text - S.Res.14: A Resolution Affirming That the Government of Cuba's Foreign Medical Missions Constitute Human Trafficking.” Congress.gov, January 10, 2019. 21 Pais, Monica. “Health Organization Accused of Trafficking Doctors to Brazil.” Courthouse News, December 4, 2018.. 22 Araujo, Gabriel. “Brazil to Hire More Doctors to Fight Coronavirus, Including Cubans.” Thomson Reuters, March 16, 2020. has built a 2-3% defection rate into the program23, which means that actual numbers may be higher due to allegations that their reported numbers regarding treatment rates are inflated. Brain Drain: The Cuban Medical Professional Program Although the United States’ “wet foot, dry foot” policy for Cuban immigrants permitted medical defectors to legally seek a green card if they made it to US soil, they did not formally promote defection until 2006. The “Cuban Medical Professional Program” (CMPP) was a joint effort announced in August 2006 by the Department of State and Department of Homeland Security24. The program authorized Citizenship and Immigration Services to grant visas to enter and remain in the United States, to any Cuban medical personnel “conscripted” by the Cuban government to work abroad. Under the law, “doctors, nurses, physical therapists, sports trainers, paramedics, and lab technicians” were all considered medical personnel. This program did not require a “dry foot”, as Cuban medical personnel could apply from the consulate or embassy of the country they were in and be granted parole into the United States. Medical personnel accepted under the program could apply for a work visa immediately and residency after a year in the United States. Spouses and children were also given visas if the application was accepted, although many Cuban doctors were sent abroad without their families which complicated this issue. The US Government denied that the CMPP was created for political reasons and instead claimed that they were motivated by humanitarian concerns related to human trafficking. Additionally, the US government claimed that Cuba purposely blocked visa applications to the United States from medical personnel, effectively prevented them from immigrating to the US25. 23 Ibid. “Fifty Years of Cuba's Medical Diplomacy: From Idealism to Pragmatism.” “Cuban Medical Professional Parole Program.” U.S. Department of State, January 26, 2009. 25 Ibid. “Brain Drain Politics: The Cuban Medical Professional Parole Programme”. 24 The State Department never released numbers on the number of defectors who took advantage of the program, but “Brain Drain”, using figures from the Wall Street Journal26, claims that 1,574 from 65 countries took advantage of the program between 2006 and 2011. Nearly all of the defectors from this period came from the Western Hemisphere, with Venezuela and Colombia making up 2/3 of all defections. This, claims “Brain Drain”, made the program relatively ineffective during those years, as 1,574 medical personnel out of roughly 83,000 sent abroad during those leads to a defection rate of 1.89%, lower than the Cuban government’s expected range of 2-3%. The piece suggests that this could be related to the clause in the Program that prevents acceptance due to anything that would make someone ineligible for regular immigration to the United States. Membership of a Communist Party within 10 years is grounds for rejection from immigration, and many Cuban doctors were registered under such organizations due to the political structure of Cuba. This oversight, combined with a lack of resources granted to personnel who are granted visas, may have undermined the Program’s effectiveness in encouraging defection. Despite this difficulty, the program resulted in thousands of defections and considerable media coverage of Cuba’s alleged human trafficking between 2006 and 2017. The Miami Herald estimates that 8,000 medical personnel defected to the United States as part of the program27 and a 2017 Congressional report by Senator Menendez has a similar figure of 7,117 with the difference likely being made up of doctors who were awaiting approval when President Obama abruptly ended the program in January 201728. That same report by Senator Menendez urged The 26 Millman, Joel. “New Prize in Cold War: Cuban Doctors.” The Wall Street Journal, January 15, 2011. Ibid. “Cuban Physicians Still Abandoning Missions Abroad despite End to U.S. Parole Program.” 28 Menendez, Robert. “Menendez Leads Congressional Call to Reinstate Cuban Medical Professional Parole Program”. US Senate. December 4, 2017. 27 Trump Administration to consider reinstating the program, citing the continued difficulties faced by Cuban doctors abroad who seek refuge in the United States. Improved Diplomatic Relations The first indicator of a shift in US policy towards Cuba, including its medical exports, came in 2009 when President Obama announced that he would be pursuing a “thaw” in relations with Cuba29. In 2014, during his announcement that the US would be seeking diplomatic relations with Cuba and ending its embargo, President Obama said: “Cuba has sent hundreds of health care workers to Africa to fight Ebola, and I believe American and Cuban health care workers should work side by side to stop the spread of this deadly disease.”30 Although he followed this statement with a discussion on human rights concerns about Cuba, he never explicitly acknowledged that the doctors Cuba sent to fight Ebola were considered as “slave labor” by some. In 2016, President Obama praised both the life expectancy of Cubans due to their healthcare system31 and advocated for partnerships between American and Cuban doctors on vaccine research. Again, neither of these statements were followed by any mention of potential human trafficking or wage garnishing. A 2015 report by Reuters suggested that Cuba’s human rights rating was overinflated in a report by the State Department, which further called President Obama’s views on the potential human trafficking of doctors into question32. After years of praising Cuba’s healthcare system and the quality of its doctors, President Obama officially ended the CMPPP in January 2017, one week before President Trump took 29 Stolberg, Sheryl Gay, and Alexei Barrionuevo. “Obama Says U.S. Will Pursue Thaw with Cuba.” The New York Times, April 17, 2009. 30 Obama, Barack. “Statement by the President on Cuba Policy Changes.” National Archives and Records Administration, 2014. 31 Roy, Avik. “Barack Obama Extols Cuba's Slave-Labor Medical Care.” Forbes, April 5, 2016. 32 Spetalnick, Matt. “Obama Administration Faces Criticism over Human Trafficking Report.” Thomson Reuters, August 4, 2015. office. After praising collaboration between the US and Cuba, President Obama wrote: “By providing preferential treatment to Cuban medical personnel, the medical parole program contradicts those efforts and risks harming the Cuban people. Cuban medical personnel will now be eligible to apply for asylum at U.S. embassies and consulates around the world, consistent with the procedures for all foreign nationals.” His statement did not detail exactly how the program was harming Cuban people but suggests that collaboration between US and Cuban doctors is more beneficial for Cubans than the CMPPP. This announcement also ended the “wet foot, dry foot” policy for Cuban immigrants, meanings that Cubans who made it to US soil and were ineligible for humanitarian relief would be deported to Cuba. This abrupt change in policy did not come without backlash and confusion. Hundreds of doctors stationed in countries awaiting acceptance into the US were suddenly unsure of their future. As they were considered “illegal” in these countries and would be met with retaliation if they were returned to Cuba, this uncertainty was understandably frightening33. The policy was quickly clarified to include a clause that applications would be processed as normal for anyone who submitted paperwork before President Obama’s announcement. There was no guarantee in the policy change, however, that doctors who were now not guaranteed entry to the United States would have any level of extra protection if they returned to Cuba or were deported by their host country. After the CMPPP was discontinued, some doctors still chose to defect, particularly in Venezuela due to crime and a lack of resources, and reach the United States through the Mexican border to apply for political asylum. At least dozens of other doctors, however, had not made it to the Colombian US Embassy in time to submit applications before the program ended34. By 33 Ibid. “Cuban Doctors Get a New Shot at Emigration - If Applications Were Submitted Prior to Cutoff.” Sesin, Carmen. “Cuban Doctors Stranded: Can't Travel to US, Cuba, or Stay in Colombia.” NBCNews.com. NBCUniversal News Group, February 20, 2017. 34 January 2017, these Cuban doctors were aware that President Trump would be taking office and that political asylum, family reunification, and even the minimum 20,000 yearly visas granted by the US to Cuban immigrants were at risk35. A Human-Centered Approach The first four years of The Trump Administration have demonstrated that Cuban doctors abroad, and those who but were seeking to be reunited with family in the US, had every right to be fearful of their status. Despite a return to restricted, unfriendly relations between the United States and Cuba, President Trump has ignored calls from other legislators to reinstitute the program36. Additionally, the Cuban Family Reunification Program was frozen in 2017 after the withdrawal of US employees from the embassy in Havana37. Nearly 20,000 applications are frozen in the system, including those from families of Cuban doctors who defected or made it to the US before the wet foot, dry foot policy was ended. The US has not honored its 20,000-visa policy since President Trump took office and short-term visit visas decreased from 16,335 in 2017 to 6,959 in 201838. The only direct references from The Trump Administration to Cuban medical exports is the threat of visa restrictions for “officials involved in the program”39 by Secretary of State Mike Pompeo and a congratulations to Bolivia for sending doctors back to Cuba after President Evo Morales lost power40. 35 “Diez Puntos Claves Del Nuevo Acuerdo Migratorio Entre Cuba y Estados Unidos.” Granma.cu. Granma. January 13, 2017. 36 Ibid. “Menendez Leads Congressional Call to Reinstate Cuban Medical Professional Parole Program” 37 Torres, Nora Gámez, and Mario J. Pentón. “Trump's Immigration Policies Keep More than 20,000 Cubans in Limbo.” miamiherald. Miami Herald, May 30, 2019. 38 Ibid. “Trump's Immigration Policies Keep More than 20,000 Cubans in Limbo.” Press, Associated. “U.S. Restricts Visas for Cuban Officials Involved in Sending Doctors Abroad.” Public Broadcasting Service, July 26, 2019. 40 “Pompeo Congratulates Bolivia for Expelling Cuban Doctors.” OnCubaNews English, November 19, 2019. https://oncubanews.com/en/cuba-usa/pompeo-congratulates-bolivia-for-expelling-cuban-doctors/. 39 Dr. Yoandra Muro, who was stationed in Bolivia until she was forcibly removed by the same police officers she once took care of, stated: “What a contradiction! Either we’re victims or we are threats.” This quote highlights that Cuban medical professionals are people, not just diplomatic tools or chess pieces in a game of international politics. The changes in policies and ideologies in nations like Brazil, Bolivia, and the United States have lasting impacts on real people. For patients, it means a lack of medical care due to no local doctors. For doctors, it could mean returning to a country you intended on defecting from or returning to a job where you make less than you did while on a mission and are unable to support your family. The claims of human trafficking made against the Cuban government are valid and serious, but no political leader making these claims is offering asylum to Cuban doctors or organizing for better treatment. If leaders like Pompeo or Bolsonaro are truly making these allegations out of concern for human rights, why are they not implementing parole and other assistance policies to help medical personnel? Despite objections from nations who oppose Cuba’s medical exports, the COVID-19 Pandemic has only bolstered the program. Cuba has sent doctors from the Henry Reeve Emergency Contingent to 17 nations during the pandemic, including Italy early in the outbreak41. This again allows Cuba to generate positive press for its program and form key diplomatic relations as nations have turned to them for help in this crisis based on their reputation. Granma, the official paper of the Communist Party of Cuba, has already created the #CubaSalva trend for global social media, accompanied by an extensive list of the nations they have worked with 41 Anthony Faiola, Kimberley Brown. “U.S. Allies, Encouraged by Washington, Said Goodbye to Their Cuban Doctors. As Coronavirus Surges, Some Are Arguing for Their Return.” The Washington Post, April 10, 2020. during the pandemic42. They make sure to depict nations that have rejected Cuba’s aid as biased by “political instability, neoliberalism in its purest state, and a hatred of our social system.”43 Among the nations alluded to by Granma are Ecuador, Bolivia, and Brazil who have all sent doctors back to Cuba in the past 2 years. The US State Department dismissed Cuba’s support during the pandemic as “a scheme to generate income that exploits medical workers”, but Latin American nations are feeling a gap left by Cuban doctors, specifically specialists and rural doctors44. Again, this highlights the highly personal effects of using Cuban doctors as a diplomatic weapon. A shift in ideology to the right in these nations, including the United States, has turned doctors into a representation of a system they are ideologically, and perhaps morally, opposed to. These nations may be in different situations if they had addressed their concerns with Cuban doctors by offering a parole program or improving working conditions for these doctors that allow them to stay without being “slave labor”. Conclusion Ultimately, the 21st Century has seen a sharp shift towards diplomatic relations between Cuba and the United States followed by a sharp shift away from diplomacy. A combination of these, with the addition of President Trump’s anti-immigration policies, has impacted Cuban doctors who seek to defect to the United States. Defectors who made it to the US before the CMPPP are now struggling to reunite with their families and professionals who are defecting now are considering entering through the Southern border for political asylum. While accusations of human trafficking and mistreatment of medical personnel by the Cuban 42 Ibid. “#CubaSalva: Práctica Humanista De La Revolución.” Ibid. “#CubaSalva: Práctica humanista de la Revolución” 44 Ibid. “U.S. Allies, Encouraged by Washington, Said Goodbye to Their Cuban Doctors.” 43 government are important to address, recent rhetoric by the United States and allies in Latin America appear to be more politically motivated than human rights-oriented. No nation has made a serious attempt to welcome defectors and have instead chosen to send doctors back to Cuba, the alleged perpetrator of human rights violations. The COVID-19 outbreak has further demonstrated that Cuba’s medical exports will remain an effective form of soft power unless another nation provides a viable alternative.