By NIRAN AL-AGBA, MD (3)
Today, the export of medical personnel generates nearly $11 billion annually for the Cuban Government and has surpassed tourism as the single largest source of income for the island country. Cuba uses the revenue generated by their “army of white coats” to fund their nationalized healthcare system. Before jumping on the single-payer healthcare bandwagon, Representative Pramila Jayapal [D-WA -7] and others supporting Medicare for All legislation, should be able to explain how to fund the monumental undertaking of a single-payer system.
There are two countries in this hemisphere with true single-payer healthcare systems: Canada and Cuba. The pros and cons of Canadian healthcare have been debated extensively, but for most Americans, knowledge about Cuban healthcare has been gleaned from Michael Moore’s movie, Sicko.
Canada has reigned in cost by rationing. Waitlists are commonplace for our neighbors to the north. Cuba has handled the cost conundrum quite differently; by conscripting physicians and even worse, through trading their physicians for cold, hard cash. Our founding fathers did everything in their power to guard against government “ownership” of goods, people, and services. What will happen once physicians are “owned” by the U.S. government? The Cuban healthcare system may provide some insight.
In 1959, the Castro administration delivered on their revolutionary campaign promise to provide a government that was more attentive to needs of the disenfranchised. Honoring socialist tenets, Cuba established healthcare access as a fundamental right of its citizens. A true single-payer system was implemented, outlawing any private market, and the government assumed total fiscal and administrative responsibility for the provision of health care.
Focusing heavily on wellness and prevention kept costs under control at around 10-15% of the GDP. The government expanded medical education to the point of creating a physician surplus, with a ratio of one physician per 180 people, exceeding that of most developed countries of the world.
Initially, Cuba made great strides in improving the health of its citizens. Life expectancy increased and infant mortality dropped below that of the United States. However, when citizens live longer and fewer die in infancy, more lives lead to higher expenditures.
More than fifty years ago, Cuba began using physicians –considered a commodity– as a diplomatic tool. In 1963, 56 Cubans replaced French doctors leaving Algeria and sending physicians abroad for humanitarian work boosted Cuba’s public relations status to the extent that the endeavor has become profitable.
Since the government controls healthcare, they control the physicians. In order to pay for “free healthcare” Cuba trades physician labor for cash with countries like Algeria, Kenya, Uganda, and Brazil. Because in reality, nothing is “free.” Due to the fact that physicians in Cuba earn about $50 per month, an estimated 35-48% of Cuban doctors are willing to sign contracts to work outside the country.
There are, of course, some drawbacks to international physician trafficking. First, exporting doctors has left a domestic health system under increasing pressure. With the dwindling number of primary care and specialty doctors staying in Cuba, wait times at clinics and hospitals have grown and resources and supplies are stretched thin. In rural areas, some physicians practice medicine in conditions without electricity or running water. Second, a legalized system of physician trafficking is ripe for corruption.
In 2013, Cuba and Brazil struck a deal, to pay $4000 per doctor per month to the Cuban government, amounting to $360 million annually. The program, known as Mais Medicos – literally ‘More Doctors’ – was established by the former Brazilian President Dilma Rousseff. From that $4000 payment, the Cuban government pays their physicians a monthly wage of $1000, though withholds $600 of that in a “frozen” account which physicians cannot access until they return to Cuba.
The Cuban government keeps a very tight rein on their doctors, akin to ranchers herding livestock. In addition to withholding physician wages, Cuba does not allow the physicians to bring their families along with them internationally, enforces a daily 6pm curfew while physicians work in foreign countries, and forces physicians to report to Cuban intelligence officers stationed in Brazil and other locales to maintain control over Cuba’s most valuable asset.
In 2017, Cuba tightened restrictions even more by banning them from taking Brazilian medical exams and compelling pregnant doctors to return to Cuba after 22 weeks gestation to prevent their children from gaining Brazilian citizenship by being born there. It was at this point Jair Bolsonaro, Brazil’s President-elect, denounced the Mais Medicos program, calling it “modern day slavery.” He took issue with the fact that Cuba absconds with 75% of the physician salaries paid by Brazil and that physician mothers were denied the right to have their children with them.
Of course, the Cuban-Brazil quagmire would not be possible without assistance from the Washington DC -based Pan American Health Organization (PAHO), a specialized health agency affiliated with the World Health Organization and the United Nations, that strives to “improve and protect the health of people.” PAHO generates income from “annual contributions from member governments” such as the U.S. and other foreign countries.
Brazil pays $1.5 billion to Pan American Health Organization (PAHO) annually for administering the Mais Medicos program plus operating expenses on top of that. PAHO paid $1.3 billion to Cuba, keeping $75 million (a 5% cut) for itself. Interestingly enough, 83% of PAHO’s capital investment real estate fund (over $1.1 million) in 2018 was spent on renovations for their Washington DC Headquarters rather than being reinvested in infrastructure in foreign countries with whom they do business.
In November 2018, a group of courageous Cuban physicians filed a lawsuit against PAHO, alleging the organization “knowingly provided, obtained, and benefitted from the forced labor and trafficking of more than 10,000 Cuban Doctors in Brazil between 2013 and the present.” It is conceivable that a UN agency may be running a legal for-profit slave trade.
Socialism can be defined simply as a stage somewhere between capitalism and communism. This political ideology enables ownership of the means of production, which are inputs– like raw materials, facilities, goods or even people — which generate revenue. In a socialist system, a central power controls the means of production and the goods produced, which may someday include U.S. doctors.
Nearly 40,000 Cuban healthcare professionals have been “leased” out to 67 countries, including eighteen thousand physicians. The Cuban government has monetized their physician workforce to the tune of $11 billion annually, in order to fund the “free” national health system in Cuba. This “army of white coats” has surpassed the economic value of tourism, becoming one of the main sources of income for the Cuban government.
Is this the future our forefathers envisioned for our democratic republic? Will a “free” national healthcare system somehow be inexplicably immune to corruption? No. Just ask all those movie stars who allegedly bought college admission into Yale, Stanford and Georgetown University for their children. In reality, everything is for sale if the price is high enough….and then we are right back to where we started at capitalism.