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1 Origins and Evolution From“Beggar’s Helper”to a“White-Jacketed Army” Of all the so-called developing nations, Cuba has by far the best health system. And their outreach program to other countries is unequaled anywhere. President Jimmy Carter, interviewed in the documentary Salud! Cuba initiated its role in medical internationalism (MI) in 1960, when a team of emergency medicine specialists flew to Chile following a devastating earthquake. Since then it has been involved in scores of medical missions , saving millions of lives. President Carter’s comment is therefore pertinent , since no country has come close to equaling Cuba’s humanitarian cooperation, particularly in developing countries. Yet surprisingly little is known about the extent of this contribution, given the extremely limited media coverage. Moreover, it strains the imagination to think that a poor country in the Caribbean could play such a major role in international medical cooperation. Cuba is indeed a poor country. Gross Domestic Product per capita is an estimated $10,200 (compared with $15,600 in Mexico or $12,800 in Costa Rica). Exports are just $5.972 billion (2012 estimate), compared with $370.9 billion and $11.44 billion. For the other two countries, while reserves of foreign exchange and gold in Cuba are just $4.69 billion, compared with $167.1 and $6.85 billion (as of 2012).1 The right-wing Heritage Foundation sums up Cuba’s “socialist command economy” as being “in perennial crisis. The average worker earns less than $25 a month, agriculture is in shambles, mining is depressed, and tourism revenue has proven volatile.”2 A more balanced (but still critical) analysis was done by Richard Feinberg for the Brookings Institution in 2011. Citing United Nations Development Program data, he noted that per capita national income on a purchasing power parity basis was $5,747—far below that of Chile ($13,651), Uruguay ($13,808), or Costa Rica ($10,870). Agricultural output in 2010 had just recovered to 2000 levels, ending a lost decade of food production. In terms Origins and Evolution: From “Beggar’s Helper” to a “White-Jacketed Army” · 15 of national investment rates, Cuba was also in the bottom 10th percentile in the world, while Cuban exports of $4 billion in merchandise goods were less than 10 percent of its annual output. The ratio of exports to GDP for Cuba was 20 percent (compared with 38 percent for Chile, 43 percent for Costa Rica, and 61 percent for Barbados). Moreover, Cuba had an external debt of $31.6 billion. Feinberg sums up his findings, noting that Moody’s rated Cuba as a Caa1 level in terms of investment risk and concluding, “In short, Cuba is both illiquid and insolvent.”3 Clearly, government rhetoric aside, the Cuban economy was in poor shape. Yet despite the statistics and the poor economic record, Cuba continues to provide an extraordinary example of humanitarianism. How can this be possible? How did Cuba’s commitment originate and evolve? This chapter seeks to provide a framework for the rest of the book and to offer a basis for an understanding of these fundamental questions. It does so by analyzing the distinctive periods of Cuban medical cooperation and by providing data and observations on the characteristics and significance of each phase. This will make it easier to understand both the rationale behind, and the extent of, the medical internationalism program that has developed over the past five decades. At the risk of erring on the side of being too simplistic, there appear to be four central periods when medical cooperation was particularly noticeable: in the early 1960s in the midst of revolutionary fervor, in the late 1970s (particularly in Africa following Cuba’s major military role in Angola), in the late 1990s following two devastating hurricanes in Central America and the Caribbean, and after 2008, when Raúl Castro assumed the presidency of Cuba and the Communist Party of Cuba produced the lineamientos, guidelines to improve productivity that were later amended and approved by the Communist Party of Cuba. Cuba and Internationalism In the introduction, mention was made of the importance of international cooperation for Cuba, dating from the late nineteenth century, when volunteers from many countries came to support the fight for independence from Spain. Since 1959, government support for internationalism has been a constant, ranging from military aid in the 1960s for revolutionary struggles in several Latin American and African countries to civilian support, mainly in medicine, education, and construction, which developed apace...


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