La Salud como Moneda: El Milagro Médico de Cuba y sus Contradicciones

"El Período Especial." I remember writing about this.

The economy contracted by something like 35 percent in four years.

People lost dramatic amounts of weight because food imports collapsed.

And the healthcare system, which looked so impressive on paper, suddenly had no medicine, no spare parts for the machines, no fuel for the ambulances.

Exacto.

Exactly.

Y lo paradójico, lo verdaderamente irónico, es que durante el Período Especial Cuba siguió formando médicos.

And the paradox, the truly ironic thing, is that during the Special Period Cuba kept training doctors.

Seguía teniendo las facultades de medicina, los programas de residencia, el énfasis en la atención primaria.

It kept its medical schools, its residency programs, its emphasis on primary care.

Lo que no tenía era paracetamol.

What it did not have was paracetamol.

Tenías médicos brillantes y no tenías analgésicos básicos.

You had brilliant doctors and you did not have basic painkillers.

Eso te dice todo sobre la naturaleza del sistema.

That tells you everything about the nature of the system.

So the human capital survived but the material infrastructure collapsed.

And I think that distinction is crucial, because it explains why Cuba's healthcare story reads so differently depending on who's telling it.

The public health scholars look at outcomes, at the indicators, and they see a real achievement.

The dissidents and the Cuban emigres look at the lived experience and they see something closer to managed neglect.

Bueno, hay que añadir otra capa a esto.

We need to add another layer to this.

Cuba tiene un sistema de salud que funciona de manera radicalmente distinta según a quién estás tratando.

Cuba has a healthcare system that functions in radically different ways depending on who you are treating.

Existe lo que informalmente se llama la medicina de la nomenklatura, los hospitales bien equipados, con medicamentos disponibles, reservados para los altos cargos del partido y para los turistas extranjeros que pagan en divisas.

There is what is informally called nomenklatura medicine, the well-equipped hospitals with available medications, reserved for senior party officials and foreign tourists who pay in hard currency.

Y luego está el sistema para el ciudadano común, que es una historia completamente diferente.

And then there is the system for ordinary citizens, which is a completely different story.

The two-tier system.

And that's not unique to Cuba, obviously.

You see that in a lot of authoritarian states.

But it's particularly jarring in Cuba because the whole ideological justification for the revolution, the thing Castro pointed to again and again, was healthcare equality.

Universal access.

The idea that a child in Santiago had the same chance as a child in Havana.

La verdad es que antes de la revolución, Cuba era un país con una sanidad muy desigual, concentrada en La Habana y casi inexistente en las zonas rurales.

The truth is that before the revolution, Cuba was a country with very unequal healthcare, concentrated in Havana and almost nonexistent in rural areas.

Los primeros años del sistema revolucionario sí representaron una mejora real para mucha gente, especialmente en el campo.

The early years of the revolutionary system did represent a real improvement for many people, especially in the countryside.

Eso es innegable.

That is undeniable.

El problema es que el régimen congeló ese relato en 1965 y ha seguido usándolo como propaganda durante sesenta años, mientras la realidad del sistema se deterioraba.

The problem is that the regime froze that narrative in 1965 and has continued using it as propaganda for sixty years, while the reality of the system deteriorated.

Look, I spent enough time in Havana to know that the relationship between what the government says and what is actually happening on the ground has a kind of creative flexibility.

But let's talk about medical diplomacy, because this is the piece of the story that I find genuinely fascinating and genuinely complicated.

Mira, la diplomacia médica cubana es uno de los fenómenos más interesantes de la política exterior del siglo XX y lo que llevamos del XXI.

Look, Cuban medical diplomacy is one of the most interesting phenomena in the foreign policy of the twentieth century and what we have seen so far in the twenty-first.

Cuba ha enviado médicos a más de 60 países.

Cuba has sent doctors to more than 60 countries.

En algunos momentos ha tenido más de 50.000 profesionales sanitarios trabajando en el extranjero simultáneamente.

At some points it has had more than 50,000 health professionals working abroad simultaneously.

En Venezuela, en Angola, en Brasil, en Haití después del terremoto de 2010.

In Venezuela, Angola, Brazil, Haiti after the 2010 earthquake.

Es la mayor operación de cooperación médica que ha realizado un país pequeño en toda la historia moderna.

It is the largest medical cooperation operation ever carried out by a small country in all of modern history.

And I've seen those Cuban medical missions up close.

I reported from Caracas during the height of the Venezuelan Misiones program, and the Cuban doctors were everywhere.

In the barrios, in places where Venezuelan doctors had never gone.

And the people receiving that care were genuinely grateful.

Whatever you think of the politics, the doctors were real and the care was real.

Es que ahí está el nudo de la cuestión.

That is the crux of the matter.

La asistencia médica es genuina, los médicos están bien formados, el impacto en las comunidades es real.

The medical assistance is genuine, the doctors are well trained, the impact on communities is real.

Pero el modelo tiene una dimensión económica y política que no se puede ignorar.

But the model has an economic and political dimension that cannot be ignored.

Cuba cobra por esas misiones.

Cuba charges for those missions.

Venezuela pagaba con petróleo.

Venezuela paid with oil.

Brasil pagó con dinero en efectivo a través del programa Más Médicos hasta que Bolsonaro lo canceló en 2018.

Brazil paid cash through the Mais Médicos program until Bolsonaro canceled it in 2018.

El Estado cubano recibe el dinero y le paga al médico una fracción pequeña.

The Cuban state receives the money and pays the doctor a small fraction.

Es, en cierto sentido, trabajo exportado.

It is, in a certain sense, exported labor.

Some people call it modern indentured servitude.

Others call it a reasonable exchange between a state that needs hard currency and a professional who gets training, travel, and relative privilege.

I've heard Cuban doctors describe it both ways, sometimes the same doctor in the same conversation.

La verdad es que la situación ha empeorado mucho desde 2019, 2020.

The truth is that the situation has deteriorated significantly since 2019 and 2020.

Cuba está en una crisis económica profunda, con apagones de 12 horas, escasez de alimentos, y una emigración masiva.

Cuba is in a deep economic crisis, with twelve-hour blackouts, food shortages, and massive emigration.

Muchos de los médicos más jóvenes y mejor formados están abandonando el país, no para ir a misiones oficiales, sino directamente a Estados Unidos, España, Chile.

Many of the youngest and best-trained doctors are leaving the country, not to go on official missions, but directly to the United States, Spain, Chile.

El sistema está perdiendo precisamente a la gente que necesita para sostenerse.

The system is losing precisely the people it needs to sustain itself.

The extraordinary thing is that this creates a kind of medical brain drain that is almost a perfect inversion of the medical diplomacy story.

For decades Cuba exported doctors as a strategic choice.

Now it's losing doctors as a symptom of collapse.

Same phenomenon, completely different cause.

A ver, en 2023 y 2024 Cuba registró algunas de las tasas de emigración más altas de su historia.

Look, in 2023 and 2024 Cuba recorded some of the highest emigration rates in its history.

Más de 700.000 personas salieron del país en un período de dos años.

More than 700,000 people left the country over a two-year period.

Y entre ellos, una proporción desproporcionada de profesionales sanitarios.

And among them, a disproportionate share of healthcare professionals.

Lo cual es devastador para un sistema que ya funcionaba con recursos muy ajustados.

Which is devastating for a system that was already running on very tight resources.

Las listas de espera se han disparado, hay operaciones que se posponen meses, y los medicamentos básicos directamente no se consiguen.

Waiting lists have skyrocketed, operations are postponed for months, and basic medications simply cannot be found.

So let's bring this back to the embargo, because that's always the conversation you have to have when you talk about Cuban healthcare.

The Cuban government blames the US embargo for the medicine shortages.

American critics say the government is using the embargo as an excuse to avoid accountability.

And I think both of those things can be true simultaneously, which is uncomfortable for everyone.

El embargo estadounidense, que en Cuba llaman el bloqueo, tiene un impacto real y documentado en el acceso a medicamentos y equipamiento médico.

The US embargo, which in Cuba they call the blockade, has a real and documented impact on access to medicines and medical equipment.

Muchas empresas farmacéuticas multinacionales evitan vender a Cuba por miedo a las sanciones secundarias, aunque técnicamente las medicinas están excluidas del embargo desde los años 90.

Many multinational pharmaceutical companies avoid selling to Cuba out of fear of secondary sanctions, even though medicines have technically been excluded from the embargo since the 1990s.

El miedo legal es suficiente para disuadir a muchos proveedores.

The legal fear is enough to deter many suppliers.

Eso es real.

That is real.

I covered the Obama thaw in 2014, 2015, and there was a moment where it looked like that whole dynamic might change.

The normalization of relations, the reopening of embassies.

And one of the immediate practical effects people were talking about was exactly this: easier access to medicines, biomedical equipment, the possibility of Cuban pharmaceutical companies licensing their discoveries internationally.

Y Cuba tiene avances farmacéuticos genuinos, que es otro de los aspectos que la gente desconoce.

And Cuba has genuine pharmaceutical advances, which is another aspect that people are unaware of.

Desarrollaron uno de los primeros tratamientos para la retinopatía diabética, que es la principal causa de ceguera en adultos.

They developed one of the first treatments for diabetic retinopathy, which is the leading cause of blindness in adults.

Tienen una vacuna contra el cáncer de pulmón, el Cimavax, que ha generado interés real en centros de investigación de todo el mundo.

They have a lung cancer vaccine, Cimavax, which has generated real interest in research centers around the world.

Y durante el COVID desarrollaron sus propias vacunas, Soberana y Abdala, con eficacias que distintos estudios han evaluado de formas muy distintas.

And during COVID they developed their own vaccines, Soberana and Abdala, with efficacies that different studies have evaluated in very different ways.

The COVID vaccines are a good example of the complexity, right?

Cuba vaccinated most of its population with domestically produced vaccines.

That's an extraordinary logistical and scientific achievement for a small island under embargo.

And the mortality numbers during the Delta wave look reasonably good.

But the independent verification of the efficacy data has been, let's say, incomplete.

Mira, ese es el problema estructural.

Look, that is the structural problem.

Cuba produce investigación médica real, pero en un contexto donde los datos son controlados por el Estado, donde los investigadores independientes tienen acceso limitado, y donde el incentivo político de presentar buenos resultados siempre está presente.

Cuba produces real medical research, but in a context where data is controlled by the state, where independent researchers have limited access, and where the political incentive to present good results is always present.

Entonces no es que la ciencia cubana sea falsa, sino que no puedes verificarla con los mismos estándares que aplicas a cualquier otro sistema.

So it is not that Cuban science is false, but that you cannot verify it with the same standards you apply to any other system.

Y esa opacidad es un problema científico, no solo político.

And that opacity is a scientific problem, not just a political one.

And this loops back to the prisoners, actually.

When the Cuban government says health is a criterion for release, we face exactly the same problem.

We can't independently verify who is being released and why.

We have no access to prison medical records.

We have the government's word.

Which, given the track record, is not quite enough.

Es que hay precedentes muy concretos.

There are very concrete precedents.

En 2010, durante el gobierno de Raúl Castro, Cuba liberó a 52 presos políticos bajo presión de la Iglesia Católica y del gobierno español de Zapatero.

In 2010, during Raúl Castro's government, Cuba released 52 political prisoners under pressure from the Catholic Church and the Spanish government of Zapatero.

Algunos de ellos salieron directamente en silla de ruedas, en condiciones físicas muy deterioradas.

Some of them left in wheelchairs, in very deteriorated physical condition.

Entonces la salud no era una concesión humanitaria, era el resultado del encarcelamiento.

So health was not a humanitarian concession, it was the result of the imprisonment.

La liberación llegó cuando ya el daño estaba hecho.

The release came when the damage had already been done.

I interviewed one of those men.

He'd been in prison for eight years, had untreated hypertension, had lost most of his teeth.

And he told me, he said, the government called it a humanitarian gesture.

I called it a transfer of liability.

They didn't want to be responsible for my death, so they released me just in time for someone else to deal with it.

Esa frase es perfecta.

That phrase is perfect.

"Una transferencia de responsabilidad." Porque eso es exactamente lo que es en muchos casos.

A transfer of liability.

Y plantea una pregunta más amplia: ¿hasta qué punto los sistemas de salud en contextos autoritarios funcionan como instrumentos de control social además de como instrumentos de cuidado?

Because that is exactly what it is in many cases.

Cuba no es el único ejemplo.

And it raises a broader question: to what extent do healthcare systems in authoritarian contexts function as instruments of social control in addition to instruments of care?

Lo ves en Venezuela, lo ves en Bielorrusia, lo ves en Nicaragua.

Cuba is not the only example.

Health as a political instrument.

Access to care as a reward for loyalty.

Denial of care as a punishment.

It's not subtle.

And it's not ancient history.

The Soviet Union used psychiatric hospitals to commit dissidents.

China has a documented history of harvesting organs from prisoners.

Cuba's version is softer but it follows the same logic: the state controls your body.

La verdad es que en Cuba el médico de familia, el famoso médico de barrio que es la base del sistema de atención primaria, también tiene una función de vigilancia.

The truth is that in Cuba the family doctor, the famous neighborhood doctor who is the foundation of the primary care system, also has a surveillance function.

Conoce a todos los vecinos, sabe quién falta al trabajo, quién tiene visitas extranjeras, quién tiene actitudes políticas sospechosas.

He knows all the neighbors, knows who misses work, who has foreign visitors, who has suspicious political attitudes.

No es que todos los médicos sean informadores, pero el sistema está diseñado de tal manera que esa posibilidad existe y es conocida.

It is not that all doctors are informants, but the system is designed in such a way that this possibility exists and is known.

So the doctor becomes an instrument of the state's visibility into society.

Which is a deeply uncomfortable idea, because we think of the doctor-patient relationship as something sacrosanct.

Confidential.

And here it's structurally compromised from the beginning.

Bueno, y aun así, a pesar de todo esto, el modelo de atención primaria cubano, la idea del médico que conoce a su comunidad, que hace visitas domiciliarias, que se enfoca en la prevención antes que en el tratamiento, eso ha influido en el pensamiento sobre salud pública en todo el mundo.

And yet, despite all of this, the Cuban primary care model, the idea of the doctor who knows his community, who makes home visits, who focuses on prevention rather than treatment, has influenced thinking about public health around the world.

La OPS, la Organización Panamericana de la Salud, ha citado el modelo cubano como referencia para países de bajos ingresos.

The Pan American Health Organization has cited the Cuban model as a reference for low-income countries.

Eso tampoco se puede ignorar.

That also cannot be ignored.

There's a version of Cuba's healthcare system that is genuinely worth studying, and a version that is genuinely worth condemning.

And the mistake that partisans on both sides make is refusing to hold both versions in their heads at the same time.

I've argued with people at dinner parties who treat Cuba as either paradise or hell, and it's neither.

It's a very complicated, historically specific thing.

A ver, en España tenemos una relación con Cuba que tiene capas históricas muy profundas, mucha emigración española a Cuba en el siglo XIX y principios del XX, la Guerra Civil y los exiliados republicanos que encontraron refugio allí.

Look, in Spain we have a relationship with Cuba that has very deep historical layers, massive Spanish emigration to Cuba in the nineteenth and early twentieth centuries, the Civil War and the Republican exiles who found refuge there.

Entonces la mirada española sobre Cuba suele ser más matizada que la estadounidense, que está completamente polarizada por la diáspora cubana de Miami y por décadas de política de la Guerra Fría.

So the Spanish view of Cuba tends to be more nuanced than the American one, which is completely polarized by the Cuban diaspora in Miami and by decades of Cold War politics.

I'll give you that.

The debate in the US about Cuba has been almost entirely captured by a specific political constituency for sixty years.

Which has made it very hard to have an honest conversation about what the healthcare system actually is and isn't.

Every time someone says something positive about Cuban medicine, someone screams communist propaganda.

Every time someone points out the shortages, someone screams CIA disinformation.

Es que Michael Moore no ayudó mucho tampoco, con todo el respeto.

Michael Moore did not help much either, with all due respect.

Sicko, su documental de 2007 sobre el sistema de salud estadounidense, usó Cuba como contrapunto utópico de una manera que era periodísticamente deshonesta.

Sicko, his 2007 documentary about the US healthcare system, used Cuba as a utopian counterpoint in a way that was journalistically dishonest.

Llevó a enfermos estadounidenses a la clínica para turistas en La Habana, no al hospital de barrio donde van los cubanos.

He took sick Americans to the tourist clinic in Havana, not to the neighborhood hospital where ordinary Cubans go.

Ese tipo de manipulación daña el debate durante décadas.

That kind of manipulation damages the debate for decades.

No, you're absolutely right about that.

I saw Sicko when it came out and I thought: this is going to make an honest conversation about Cuban healthcare impossible for a generation.

Because now everyone either has to defend the film or attack it, instead of just looking at the actual system.

Mira, y al final todo esto nos lleva de vuelta a los 2.010 presos.

Look, and in the end all of this brings us back to the 2,010 prisoners.

Porque ese número, 2.010, es también una cifra política.

Because that number, 2,010, is also a political figure.

Es una cantidad lo suficientemente grande como para parecer generosa, pero lo suficientemente pequeña como para no representar una ruptura real con el sistema penitenciario.

It is large enough to seem generous, but small enough not to represent a real break with the prison system.

Cuba tiene, según diferentes estimaciones, entre 50.000 y 60.000 presos en total.

Cuba has, according to different estimates, between 50,000 and 60,000 prisoners in total.

2.010 es un gesto.

Two thousand and ten is a gesture.

No es una reforma.

It is not a reform.

A gesture timed for Easter.

Timed for a moment of maximum international visibility and minimum scrutiny, because everyone's attention is on the Iran war and oil prices.

I don't think that's cynical of me to notice.

It's just the grammar of Cuban political communication.

You learn to read the timing.

La verdad es que lo que más me preocupa del sistema cubano ahora mismo no es la propaganda ni el debate ideológico.

What worries me most about the Cuban system right now is not the propaganda or the ideological debate.

Es la crisis real, concreta, que está viviendo el sistema sanitario.

It is the real, concrete crisis that the healthcare system is experiencing.

Los médicos que se van, las infraestructuras que no se reparan, la escasez de medicamentos que ha llegado a niveles que hacen casi imposible tratar enfermedades crónicas básicas.

Doctors leaving, infrastructure that is not repaired, drug shortages that have reached levels that make it almost impossible to treat basic chronic diseases.

Cuba está perdiendo en silencio algo que tardó décadas en construir.

Cuba is quietly losing something that took decades to build.

And the terrible irony is that the people who suffer most from that loss are the ordinary Cubans, the ones who never had access to the nomenklatura hospitals anyway.

The people the revolution was supposed to be for.

I mean, that's the sentence that hangs over everything when you talk about Cuba: whatever good was done, the people it was done for are paying the price for the system's failure.

Es que en el fondo, la historia de la sanidad cubana es la historia de lo que ocurre cuando conviertes un derecho en un privilegio otorgado por el Estado.

At its core, the story of Cuban healthcare is the story of what happens when you turn a right into a privilege granted by the state.

La salud deja de ser algo que te pertenece y se convierte en algo que el Estado te da o te quita.

Health stops being something that belongs to you and becomes something the state gives or takes away.

Y en ese momento, por muy buenos que sean los médicos, por muy impresionantes que sean los datos de mortalidad infantil, el sistema ha traicionado la promesa que lo justificaba.

And at that moment, no matter how good the doctors are, no matter how impressive the infant mortality figures, the system has betrayed the promise that justified it.

That's a good place to end, actually.

Health as a right versus health as a gift from power.

It's a question that isn't just Cuban.

It's the central argument in every healthcare debate in every democracy in the world, just usually without the authoritarianism to make the stakes quite so visible.

Bueno, y si alguien quiere seguir estudiando español mientras piensa en todo esto, que sepa que ha aprendido hoy palabras como mortalidad infantil, atención primaria, indulto, escasez y diplomacia médica.

And if anyone wants to keep studying Spanish while thinking about all of this, know that today you have learned words like infant mortality, primary care, pardon, shortage, and medical diplomacy.

No está mal para un episodio que empezó con 2.010 presos en una isla del Caribe.

Not bad for an episode that started with 2,010 prisoners on a Caribbean island.