Jienchi Dorward recently did his elective in Bolivia and discusses the pros and cons of the role of  Cuban doctors in the Bolivian health system

In solidarity: Bolivian President Evo Morales (middle) and the Cuban Ambassador to Bolivia

How international institutions, donors and governments can best work together to improve health is an increasingly important question in our globalised world. Amongst big players like the World Bank and the WHO, the role of one small Latin American country has long been overlooked. Cuba, the only communist country in Latin America, is world renowned for its healthcare system and health statistics to match many developed countries. (1) Its open defiance of the United States has won it many supporters in Latin American, who blame the political and economic influence of the USA for their perceived underdevelopment. (2) Cuba’s image has also been boosted by its many medical missions; there are currently over 20,000 Cuban health workers in Latin American and African countries, often working in social programs which target poor and rural areas. (3) Their presence has had big effects upon their host countries, but whether in a positive or negative way is often hotly debated. On a recent elective in Bolivia, I was able to see their work and its effects first hand.Bolivia is one of the poorest countries in Latin America, and has the highest proportion of indigenous people. (4) Its poverty is reflected in its health statistics, with high inequalities between urban and rural areas, and the majority of patients still having to pay for treatment which they often cannot afford. The election of the first indigenous president, the socialist Evo Morales, has provided hope for many social groups who have felt marginalized and repressed in the past. Morales was quick to ally himself with communist Cuba and socialist Venezuela in an agreement called ALBA (in English - Bolivarian Alternative for the People of Our America), in which Cuba and Venezuela agreed to provide funds, equipment and doctors for the Bolivian health system. (5)

In the hospital in which I worked, Cuban doctors brought a range of services including imaging and lab equipment, technicians,  and lots of medicines, all of which were free of charge for Bolivian patients who would normally have to pay. In fact, the Bolivian soldier who killed the Cuban revolutionary hero, Che Guevara, has recently had his cataracts removed by unknowing Cuban ophthalmologists for free. (6) This is all paid for by the Cuban government, who in return get cheap Venezuelan oil. Bolivia’s contribution to the agreement (apart from ‘solidarity’) remains uncertain, but its huge gas reserves may well come into play in the future. (7)

Without the Cuban’s help, the hospital would have been without many vital services. For example, there is a shortage of anaesthetists in Bolivia, and none want to work in rural areas. When the Cuban anaesthetist in my hospital went on holiday there was no surgery for two weeks. The Cubans are good doctors and often treat their patients with more respect than their Bolivian counterparts do, partly because of superior training and a more ‘charitable’ work ethic; many have ‘volunteered’ to work in Bolivia, a bit like doctors who choose to work abroad for charities like Medicins Sans Frontiers or Medicins Du Monde. This good quality, free care has made the Cubans very popular amongst patients in rural areas. However, amongst the middle classes, who are suspicious of the motives behind this communist ‘solidarity’, many question whether the Cubans are true doctors, as none of them have had their qualifications validated in Bolivia. This has been a common accusation in other countries that receive Cuban missions. (8)

Many criticisms levelled against Cuban missions have focused on political issues [i.e. that doctors are used to politically indoctrinate patients (8)]. However, the main problems that I saw were more logistical. First, the hospital was divided into two systems, the Cuban system and the Bolivian system. There were two laboratories, two pharmacies, two sets of patients’ notes and two teams on call at night. Patients would choose which service they wanted to use and not surprisingly many chose to be treated for free by the Cubans. This led to several problems: the hospital was losing revenue and therefore couldn’t employ the much needed social worker or secretary. Second, a lack of cohesion between the Cuban and Bolivian doctors lead to wastage of time and a duplication of resources. In turn, Bolivian doctors felt demoralized and unwanted from having little work to do. Finally, the Cubans work lacks sustainability. They are not training the Bolivians to fill their roles and across the country no-one knows if the agreement with Cuba will be renewed after May 2008.

All in all, the work of the Cuban doctors seemed to have many of the weaknesses that non-governmental organizations have been criticized for. The program places too much emphasis on equipment and medicines and too little on sustainability and co-ordination with existing local systems. In fact, ten thousand Bolivian doctors are unemployed according to the Bolivian Medical Association, who argue that the Cuban’s are stealing Bolivian jobs. (9) The Cuban’s claim that the posts they take up are in rural areas where Bolivian doctors refuse to work anyway.

This uncoordinated approach seems endemic in the Bolivian health system, which is full of different programs working independently of each other. Whilst a World Bank loan is being used to provide roaming rural health programs, another government run program (Family, Community and Intercultural Health) sends Bolivian doctors to live in similar rural areas, which sometimes overlap. Cuban doctors have also been sent out to isolated communities, as part of a different program. As in Venezuela, (8) the use of Cuban doctors seems to have contributed to fragmenting the healthcare system, leading to confusion over responsibilities and a waste of resources.

What is needed is better collaboration within the Bolivian health system. The weaknesses that are present need to be identified, and then strategically dealt with. Cuba can provide the highly trained personnel much needed in Bolivia’s rural areas, as well as expertise at running a cheap and effective primary care system. The World Bank and WHO have funds and experience in health sector management, although President Morales has previously refused their ‘imperialist, neoliberal’ help. There are plenty of Bolivian doctors who need work, and Bolivia’s strong social movements should mean that involving civil society in efforts to improve health and healthcare should come naturally. Instead of competing for resources and political capital, all these groups need to move beyond ideology and work practically to ensure that the dream of health for all becomes a Bolivian reality.

Jienchi Dorward
5th year medical student
University of Bristol
Bristol
jienchino@googlemail.com

(1) Kirwan D and Baguley D. (2007) Medical Education in Cuba. Student BMJ http://student.bmj.com/issues/07/11/news/386.php

(2) Galeano, E., (2006). Las Venas Abiertas de America Látina (The Open Veins of Latin America). Madrid: Siglo XXI Ediciones

(3) Carrillo de Albornoz, S. (2006). On a mission: how Cuba uses its doctors abroad. BMJ 2006;333;464.

(4) Montenegro RA, Stephens C. (2006) Indigenous health in Latin America and the Caribbean. Lancet. 367:1859-69.

(5) BBC News Online (2006). Leftist trio seals Americas pact http://news.bbc.co.uk/2/hi/americas/4959008.stm..

(6) BBC News Online (2007). Cubans treat man who killed Che. http://news.bbc.co.uk/1/hi/world/americas/7023706.stm

(7) Dangels, B., (2007). The Price of Fire: Resource Wars and Social Movements in Bolivia. London: AK Press.

(8) Cancel D (2007). In Venezuela, two public-health systems grow apart. Lancet 370:473-474.

(9) People’s Weekly World (2006). Cuba, Venezuela bring medical care to Bolivia. http://www.pww.org/article/articleview/9280/1/142/

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