🇨🇺 Cuba's Healthy Development. 🇨🇺

[Music] Hello, I'm Professor Bob Hewish from the Department of International Development Studies at Dellows University. You're listening to GDP, the Global Development Primer, with a podcast dedicated to all issues in international development studies. Follow me on Twitter @ProfessorHewish. [Music] Our guest today is Professor John Kirk, Professor of Latin American Studies at Dellows University, where he has taught since 1978. He's a co-author, co-editor, and author of 16 books on Cuba, of which the most recent are health care-level borders, understanding Cuba Medical Internationalism, and Cuban foreign policy transformation under Ravel Castro. He is currently working on a new book, analyzing Canada Cuban Relations. Today Professor John Kirk is here to talk to us about Cuba's foreign policy, Medical Internationalism, and Canada Cuban Relations. Professor Kirk, welcome to GDP. It's a pleasure to be here. It's always great to see you. You and I follow Cuba enthusiasts when it comes to our research. And I think both of us have argued in the work we've done, that Cuba tends to buck the trend when it comes to international development. Relatively low, gross domestic product, great health outcomes, great education rates, very little homelessness to none, near full employment. I guess the real question is what makes the Cuba Development Model tick? What lessons does it have for the world? I think the basic lesson is the Cuba has got the political will to share what it has, to share its human resources in many fields. Everything from engineering and sports to health care and education. It does not give its leftovers as many developed societies. I use the term developed in quotation marks, but as an industrialized society with a very low GDP, it shares what it has. Much of this comes down to the personal role of Fidel Castro when he was president. I was fortunate to interview him extensively on this, and it became very, very clear that for him access to health care is the most basic human right that anyone on the planet should have. It was a personal obsession for him, and he was determined to do what he could. Now, bear in mind, the Cuba has got three times as many physicians per capita as Canada has. So Cuba has got a surplus of physicians. So not only does it have excellent health indicators, but Cuba was able to use this richness in human talent to share it with the planet. That's incredible. So we're actually going to throw this movie in for our listeners as well. You can see here on this graph, we've got the medical doctors per thousand on the left side, and the gross domestic product on the bottom. And we've got Canada, the United States, the United Kingdom, South Africa here. And you look at this trajectory over time, and you see that the Cuba, Cuba's investment in human resources and health is outstanding. I mean, by the 1970s, they're basically parallel with the United Kingdom. 1980s, they overcome the United States. And now here in the 1980s, 1990s, there's a massive crisis, an economic catastrophe, and that's when the country becomes the one with the greatest, the best doctor to patient-ration in the world. One of the things that's interesting, Fidel Castro made the point that Cuba had the moral obligation to share its resources with the planet. It's in the preamble to the new constitution that Cuba's got a moral obligation to do this. And when the, what's called a special period hit, when the Soviet Union and the Eastern European countries, the socialist countries went bankrupt, when the Berlin war came down and when the Soviet Union imploded, Cuba had to decide what it was going to do to bring in cash, how to keep people with the best education and healthcare systems in the developing world. And so as a result, two things were brought to the fore. One was tourism. There wasn't real tourism until early 1990s. But secondly, it was the exploitation of medical services. This brings in now probably two and a half times as much as tourism does. Usually most people show that it's about $8.9 billion as opposed to $3 to $4 billion for tourism. So it makes good economic sense. And Castro had said back in 1965, "We'll never have too many doctors. We will always be able to sell medical services abroad." And at the moment, there are approximately probably about 40,000, 45,000 medical personnel working in 65 countries around the planet, mainly in developing countries. So it brings in dollars. It also, for poor countries, it also provides at no cost medical services. So here we're seeing in the 1960s, too. So in that period, so there's a few periods of really important time in Cuba's timeline. The 1990s, as you said, so the Soviet Union effectively was dissolved December 25, 1991. Those special agreements they had with Cuba to keep trade and relations in exchange for sugar just evaporated overnight. We see the economic collapse that comes with that. There's a commitment to invest resources for health needs of their own people, but also foreigners. But that extends back to the 1960s. And in the 1960s, that was before Cuba overcame the epidemiological transition they had. A lot of health challenges at home, even with the basic vaccine preventable illnesses. But even still, their medical brigades were still going abroad. That's right. To put this in context, in 1959, Cuba had 6000 physicians and one medical school. It now has 94,000 physicians and 14 medical schools, including the largest in the world, the Latin American school of medicine. Cuba in 1960, as the wealthy, white, urban-based middle class was voting with its feet, and the first person to send it to the first internationalist mission to Chile, where there was a Northquake. That was the biggest earthquake in human history. It was very, very large earthquake. Despite not having diplomatic relations with Chile, it sent people there. In 1963, to Algeria, it sent its first large medical delegation to set up the Algerian health care system. This was at a time, again, when Cuba was facing a massive exodus of its own professionals. Yet from the very get-go decided that this had to happen. Wow. And again, with Algeria, there you have a case where France was one of the few countries that was maintaining strong diplomatic ties to Cuba. But again, that conflict between France and Algeria, sending their own physicians into Algeria, it didn't really even sever ties with the French. Right. And it was a very good point to make, Bob, because in 1962, every country in the Western hemisphere, with the exception of Canada and Mexico, broke relations with Cuba. Cuba had very strained relations with Western Europe. One of the very few countries that maintained relations was France. There was a personal respect that the Castro was expressed for General Sheldagot. Despite having very few friends in the West, Cuba believed that sending internationalism, or supporting medical internationalism, was far more important than just maintaining diplomatic ties. Right. And we've seen that, not just with disanalyze, but we've seen it, the offering of medical services from Cuba to its very, very much starch opponents. Well, when Hurricane Katrina hit New Orleans, Cuba offered 1,200 medical specialists, specialist and emergency medicine, 32 tons of medicine. They were all lined up waiting to go in Havana, or sitting with their backpacks, waiting for permission from George W. Bush to come and land and help in New Orleans. The Americans never even recognized the support, let alone gave them permission to come and help. Absolutely foolish on the part of the Bush administration. In 1998, when Hurricane Mitch destroyed Central America, Cuba didn't have diplomatic relations with Honduras, with Guatemala. Yet, it sent hundreds of physicians, 900 physicians. And then decided that rather than keep physicians there, it has about 400 physicians in Central America at the moment. What was most important was to bring bright students who couldn't afford to go to medical school, to bring them to Cuba, to train them at no cost to become physicians. So hundreds of students came to study medicine at Elam de Latin American Medical School, and went back to their country. Maintains a strong medical presence, but also believed it was better to have poor kids who couldn't afford to go to medical school, to become a brain gain as opposed to a brain drain, which is, as we know, very common in the developing world. People leave their countries to go make more money in industrialized countries. Whereas what the Cubans tried to do was to reverse that and to bring into account a brain gain. There was a report done by the World Health Organization, the Pan American Health Organization, about 10 years ago, that tried to look at this out migration of human resources for health. And they found quite clearly that one of the big determinants in trying to create a sustainable rural health system. was actually having people from those areas serve those areas. And this I think is a challenge with medical schools around the world. I mean, even here in the province of Nova Scotia, there's a small crisis at the moment in Cape Breton of trying to get physicians from Cape Breton back to Cape Breton. The world's kind of scratching their head. And here's Cuba saying we can not only do this at cost, but we can do it by scaling up to the tens of thousands. I think a lot of people would ask, well, where is this coming from? Is it expensive to train a physician? And how can they train so many? Have you ever heard those sort of critiques before? Sure. I think precisely because our model insists upon a techno base, which the Cubans say is important, but for developing societies, you need more basic approaches to medicine. You need to have physicians who are using a preventive form of approach as opposed to a curative approach. Our physicians here like to see you when you come in showing symptoms of something and give you a prescription for something that's going to cost a lot of money. By contrast, Cuba produces 62% of its own medicines, so it's cheap. But more importantly, Cuba believes that you have to have a preventive approach. So a medical problem becomes treatable before it becomes too expensive. Now, a very good example is Timor Leste, East Timor, where when the country became independent, after the Indonesians left Timor, there were only 45 physicians. Cuba sent 300 physicians right away, but then used the same approach and said, we want to train physicians from Timor Leste, who are from poor communities, the wrong side of the tracks. And as you pointed out, precisely because they know what the problems are, they're more likely to stay. But these are kids who could never afford to go to medical school. So we'll give them six years of medical training, with the understanding that again, the brain gain will remain. And that's exactly what's happened in Timor. So I think that the critique that's put forward is based upon a developed industrialized model, which is not applicable in many, many ways to a developing society. You know, I think there's a really good point. I mean, when we start studying international development studies, and even the textbook for the main course that we offer here, the first chapter is about what is development. We usually start by saying, well, we envisioned this in the 1940s, 1950s, as a process of modernity. And then from there, by the time the 1970s and the 80s show up, there's quite a strong critique saying that that modernity project just didn't work out in terms of creating that equity. And there's often a strong critique of the whole infrastructure of international development within the subject. But there's very few points where we actually turn to examples that are producing results, that did meet the Millennium Development Goals, that are on the very much on the way to create the Sustainable Development Goals. And here, you know, Cuba's got that case, the case in point. One of the things with it, though, is some of the real practical skills that come from this model. So you mentioned health promotion, prevention of diseases. You've spent time with Cuban doctors in Central America. I've worked with some in Ecuador myself, and the innovation that you see from these physicians is extraordinary. There was one case in a clinic in rural Ecuador, where they were drawing blood samples. They wanted to check, I think it was pre-condition for heart disease, was on patient. Well, the bloody centrifuge was busted, right? So how these physicians, the ones were trained at the Latin American School of Medicine, said, "No problem." And off came the boot, the blood sample went into the sock, and they started whipping the sock around their head for about 10 minutes trying to create like a helicopter vision. That was enough to discombobulate the blood so that they could draw their samples. Did you see anything like that in Guatemala or Central America? Yeah, I think that both there, and also I've attended classes at Elam. And in Elam, it's interesting because very often the professors who teach the students from the various countries. There are 120 nations have taken courses at Elam. The intake is about 1400 students a year. And both there and also in the field, I've seen people use an extraordinarily practical approach. So for instance, in Elam, I remember going into a class where someone was a class of Brazilian students. And the doctor who was teaching them had spent two years in North East of Brazil in rural areas. And was able to make and give examples of what he had done. Exactly as you're saying, because he was saying, "Planse on places you go to won't have electricity. So how are you going to do this? How are you going to have the appropriate amount of testing? You've got to think on your feet. That's pretty practical." So I think the essence of what the Cubans teach in their medical school is how you resolve problems. And the Spanish word "resolverte" really important to show how you can overcome what appeared to be unbeatable problems. By saying, "No, you've got to have the political will." And in many ways the Cuban revolutionary process is a macrocosm of that. Because who would have thought that it would have survived living 90 miles away from the United States when the United States was determined to overthrow it? So political will and pragmatism have been the essence of Cubans approach to health care. Where you're seeing this now, actually, that very point, that pragmatism is actually reflected in other parts of global health. So in the global health class here, we discussed this. We put together a village health worker guide. So this year we looked at polio because even the polio is considered to be nearly eradicated. There were three major outbreaks in 2018. One was in Pakistan, one was in Mozambique, and one was in Papua New Guinea. Now the way that UNICEF actually approached this, we're one of the big funders for polio, is to say we actually don't need a better vaccine. We actually have got enough medical technology to get this done, but what we need are human resources on the ground and human resources that are trained in local context. So the reasons that you have polio still existing in northern parts of Pakistan have a lot to do with gender dynamics in that country. Whereas in Papua New Guinea, it was a complete lack of services. Where in Mozambique, it was a sanitation issue. So it seems like the Cuban approach, and with the physicians that I've worked with and you have as well, that seems to be the first chapter in engaging in the field. It's that you know the local geography, you know the context, and you don't just assume that an answer is going to come out of a medical textbook alone. That's right. And I think that the fact that the students from the various countries who are studying in Elam and Cuba, they are tuted by Cuban physicians who have spent years in the country. I know exactly the kind of diseases that they have to fight. So you have again a very pragmatic approach to resolving problems. A very good example of being aware of local conditions is can be seen in Pakistan or even in West Africa with Ebola. You remember the 2014 Ebola epidemic? That's right. The very first country that offered medical assistance was Cuba. Both the World Health Organization and the UN, Bankymone, Praise Cuba because Cuba was the very first country that answered the call. Now Cuba already had hundreds of doctors working in sub-Saharan Africa. So they're able to use many of them, but also sent 256 people from Cuba within a month there. So they had one of the largest delegations of physicians, but were able to call upon the local knowledge of physicians who'd been trained by Cuba in Havana and had then gone back to their countries. So you already had a network on the ground, a network that was very aware of local diseases and local cultures and you had to deal with it. In Pakistan after the massive earthquake, Cuba sent 2300 medical personnel. They were there for six months. When they left, they left 32 field hospitals. They took three months to train local medical people, how to use the material. They left 30 tons of medicines. Most importantly, they took a thousand kids from Pakistan, two Cuba to train them. And I was in Cuba. It was in Elam where the thousand young Pakistanis were trained to be doctors. Did they not set up a separate campus just for that crew? No. They have a separate campus for Francophone students in right in Santiago. And that's basically for the students from French West Africa and also from Haiti, specifically for Haiti. Initially, when in 1998, when Hurricane Mitch destroyed Central America, Sameer, Hurricane George in Haiti did the same thing. And Cuba, Fidel Castro closed down the Naval Academy in the west of Havana and said, we don't need the Navy as much as we need doctors for these countries. So hundreds of students flooded in from Central America and from Haiti. They then, because of the two different languages, they then set up another campus in Santiago where all the Francophone students went and still go. So Cuba's trained just over a thousand Haitians. Again, the brain gained as opposed to brain drain, but also many hundred students from French West Africa. It's amazing to think that a thousand and students just from Haiti where the World Bank in a report in 2005, I believe under former president of Haiti, John Aristide, there was an ambition put forward to try to create an upscale medical school within Haiti kind of following the Cuban model, but because Haiti was so indebted to the World Bank, World Bank said, no, we, you're just too poor Haiti to actually have a medical school year-own. So until you overcome this debt issue that's been 200 years of its history, no medical school for you. And then here's Cuba saying, no, no, we got this. Yeah, we can make it happen. Sure. It all comes down to a first world capitalist society with its model. And it says it works fine. And it's just got to be the model for the entire world. They're wrong. Right. The industrialized developed societies have got different needs, different approaches, different problems. If the purpose is to save lives, it is arrogant to have a one-size-fits-all approach without listening to local culture, without listening to local needs and adapting to suit what is appropriate for local developing societies. And I think that's that listening. That's actually really at the heart of any sort of human development. Sometimes with these discussions of Cuba, the critics say, well, this is all just the consequence of socialism. And if we look on a global scale, you see that many countries that subscribe to socialism. I'm thinking North Korea and Vietnam does certain degree. Their health systems are not something I would go out of my way to encourage people to attend. Meanwhile, you look at the history of how Cuba put its medical system together. And there's a lot of kind of stolen and borrowed moments. In 1936, there was Shemishenko model. In 1933, in Soviet Union, there was Shemishenko model about community-based healthcare, the value of that. The NHS model from Britain came out in 1947. 1962, in Canada, the US and Cuba, the decision was made, or the proposal was made that physicians should not bill patients directly for their services. Cuba went ahead with it. It took Canada another five years. And John Kennedy, who was president of the United States at the time, got a real lashing from the American Medical Association over it. 1978, you have the Alma out of declaration in Kazakhstan that said, healthcare should be a right for all. And then reinforcement of the Millennium Development Goals in 2001, now sustainable development goals, coming forward. I mean, in my mind, it seems, it comes back to your earlier point about political leadership, that if there are these good ideas out there, that if there are known best practices, what does it take for a country or a society to go ahead and do it? I think that many politicians don't practice what they preach. Cuba's do. I think it comes down to having an understanding of reality facing developing societies, along with the political commitment to make a difference. Cuba has done that in spades since 1960. Many politicians also have got a very bizarre approach to what public healthcare should be. If you listen to President Donald Trump, healthcare has got to be a private model to be any good. The Cubans would laugh at that. And so to say, if that's the case, why do we have the same life expectancy as you do, but we've got so much better rate of infant mortality. And we pay one-twelfth of per capita of what you do. So it comes down to and to putting aside the first world industrialized world arrogance and listening to people from other societies and accepting that one size does not fit ill. Yeah. That is important to look at local conditions and to adjust medical training and medical practices and to listen to people. In Guatemala, I remember interviewing some Cuban physicians way out in the bonus in an area where predominantly Maya was spoken. And they talked about how they needed to adjust to having indigenous women to deliver their babies standing. When totally against what the Cubans had been told, but precisely because this was the local custom, this is what the Cubans worked around. Likewise, working with a Kuran Deiro, a magic man or woman, they had to listen, had to use local herbs, they had to listen to local knowledge and not have an arrogant approach to it to recognize that medicine is a multifaceted phenomenon. And there is no one size fits all and no one's got all the answers. So you have to be realistic, you have to be pragmatic, you have to have the political will. That's great. I mean, you know, you hit it right on the head there. A lot of politicians don't price with the preach. They don't have the courage to do what they say they will. You know, when we talk about development projects here, the first thing that comes in the headline is how much it cost, how much money do we give to country X? Where are we four years later? Send your report to this ministry and that seems to be the concern. But in this way, Cubans got an experience of listening to best practices, right, right back to the early days. And having the courage to try is sometimes having the courage to fail along the way. I remember after the 1959 there was a program to in Havana to try to get women who were prostitutes for prostitutes employed. There was a program set up to take a lot of the confiscated cars from the detestor regime, paint them pink. And now we've got a very forward-thinking dynamic elite taxi force of women. That program didn't last too long because they didn't really invest in driver education. There's all sorts of programs that Cuba tries. Some succeed miraculously. Others tend to be a bit more quiet. We don't hear much about them. They fizzled out. But the point is they're trying. Fidel Castro, you mentioned quite a bit here. We're now two presidents on from Fidel Castro. Is this kind of political courage, the ability to try this from morality for development, I guess. We're going to see that with Miguel Diaz Canal and those that come after him. I think there has to be that political commitment. There has to be that bravery, precisely because if you look at the approach of Latin America at the moment and you look at the reality of the changing world of Latin America, when you have someone like Bolsonaro elected in Brazil, when you have very, very right-wing politicians leading a number of countries. Argentina is another good example. Chile, likewise. The so-called pink tide that existed 10 even as late as maybe five years ago has changed. So it's now a blue tsunami in Latin America. The United States under Donald Trump has adopted this unilateral approach to so many policies. It dumped Kyoto as soon as it could. It is totally opposed to multilateralism. It's called into affect the United Nations. It's skeptical about NATO. All these things indicate a changing, polarized world. Cuba, with population of 11 million living 90 miles away to possibly the most militarized society in the world, is facing major challenges. Diaz Canal, in order to maintain the national unity, has got to weld together a group of people who share that national dream, who are prepared to put up with with with sacrifice, as Cuba has done since 1959. And be prepared to to show solidarity both within its borders and abroad. It'll be a severe test for Diaz Canal, the first of the leader without the name of Castro to lead the country. I suspect that there will be many bumps along the road, but I think that most people do not want to have a US presence in the country, a large US political presence. As we look at what's happening in Venezuela and the US attempts to bring about regime change there, next up is Cuba. The Troika of tyranny as Venezuela and Nicaragua and Cuba have been called by US politicians. This is a significant and real goal for the United States and Cuba will be put to the test. I believe based upon the way it's overcome similar tests since 1959, it will do so, but it's not going to be easy. And will medical internationalism that we spoke about earlier, mix of offering medical services for foreign policy, less to be a part of the picture? Yes and no. I think it will be part of the picture, but it'll be a different approach. I think increasingly Cuba will be looking to gain hard currency through selling medical services abroad, possibly to industrialize societies. At the moment, Qatar has got a hospital with 300 Cuban personnel running the entire hospital. I think many Arab countries will increasingly take Cuban personnel. Cuba has got a huge surplus at the moment. 8,000 doctors were basically booted out of Brazil, by Bolsonaro, or 2,500 went to Venezuela, but Cuba still has got an excess of medical goods and services. The bright light is the growing biotechnology industry. Obama had permitted trials of SEMAVAX, extremely successful lung cancer vaccine in Buffalo. And those trials are continuing. If those trials are successful, it'll be very difficult for Donald Trump to prevent Cuba's medical biotechnology being used in other industrialized societies. So hopefully through the exploitation of pharmaceutical goods and the continued sale of medical goods and service, Cuba will continue. Cuba will continue to provide medical services to poor developing countries at no charge. But I think they will also be looking increasingly for places like the WHO and the UN to be able or other countries to support their endeavour. So at least Cuba in increasingly difficult economic situations will have the basic costs covered either through the UN and WHO or through donor countries. Right on. I'll ask a question for you because I have to ask, how many times have you been to Cuba? A whole bunch. People can make their own calculations. I went for the first time in 1976 when I was a graduate student at UBC and I go back an average two to three times a year. I have done since. So a lot. That is incredible. And a lot of Canadians do have to Cuba each year, million plus, am I right on that? Yeah, 1.2 million. 1.2 million. A lot of them get to a beach and don't get off the beach. Do you have any advice for people who want to explore and learn more about Cuba? Is there a place they should start? I think that people need to get off the beach. If you want to go for R&R and after the long Canadian winter, who blames you? That's fine. If you get the Cuba bug, if you want to look more, read as much as you can, learn Spanish to really understand Cuba. You've got to have one-on-one conversations with people who live the real world as opposed to people working in the tourism industry. Key factor is to develop media literacy. It's a jungle out there. And there's so much material that is absolute junk, ideologically from both the left and the right. But what is very important to do is to develop the tools so that you can read between the lines and have a solid understanding. But the key thing is to go to Cuba and explore and to wander around. It is very safe compared to any Latin American country that I've traveled to. People are very hospitable and very warm. It's still economically reasonable in terms of cost and so much to see. And as we've discussed today, the medical, the literacy, the cultural, the athletic, there are so many models we can learn from Cuba if we put aside prejudice. So put aside prejudice, go with an open mind and develop media literacy. Professor John Kirk, what a pleasure. It's always great to talk to you about Cuba. I'm sure the two of us could chat for another half hour or so if time permitted. We're going to have to leave it there and we've had today on the show Professor John Kirk from the Department of Spanish and Latin American Studies at Dall House University and also my very good tennis partner in France. It was easy to be a goalscord. And yes, it seemed to be a long bowling partner for the summer ahead. Professor Kirk, thanks again for joining us today on GDP. A great pleasure, Bob. Thank you. [MUSIC]