When the Ebola epidemic struck West Africa last year, the Cuban medical authorities were among the first to react. A contingent of 165 medical workers arrived in Sierra Leone in October to help battle the disease. Cuba swiftly trained a reported 461 doctors and nurses on Ebola treatment, and at one point it was the largest single contributor of medical workers to the crisis, outperforming countries 100 times its size. For a nation of just 11 million with a struggling economy, this was remarkable, but it was by no means the first time the Cubans had distinguished themselves in a medical emergency. Nor was it the first bilateral medical assistance provided to Sierra Leone or the other Ebola-affected countries. The Cubans have for some years provided a medical team for Sierra Leone, operating in major centres all over the country, including the main referral hospital, Connaught. The Caribbean country has also offered medical training and scholarships to Sierra Leone.

The assistance given by Cuba to Sierra Leone is but a tiny fraction of the Cuban medical effort worldwide. Cuba operates vast medical enterprises, well beyond the assumed  reach of a country of its size. Cuba exports its medical expertise around the globe,  reportedly deploying an astonishing 50,000 health professionals in 68 countries around the world, (the actual numbers vary from one report to another and also from year to year) mainly in Latin America and Africa. With the poorer countries, Cuba's medical services are provided as aid, borne of the fundamental ideological belief of the communist state that medical care is a basic right that should be provided without regard to ability to pay. For richer countries, Cuba does receive money for its medical exports, and has uniquely created a medical services export industry whilst still providing a humanitarian service to poor people. In a delicious irony, the communist state is making huge amounts of money by exporting medical services to capitalist countries who can afford to pay for them. In Latin America, for instance, Cuba provides medical personnel for Operation Miracle, a major vision restoration program launched in 2004 by Fidel Castro and Hugo Chávez, former President of oil-rich Venezuela. The program operates without charge on the Latin American poor who suffer from cataracts and other eye diseases. In a decade, nearly 3.5 million people have had their vision restored through this example of Cuban internationalism. Additionally, in a separate program, Cuban professionals are paid by Venezuela and other Latin American countries to provide health care free of charge to large, underprivileged populations in these countries. Medical tourism, where foreigners visit Cuba to utilize its medical services, is also an area of revenue.

Cuba, a small island nation, has long been overshadowed by its all-powerful neighbour, the USA, just 93 miles away across the Florida Straits. The USA maintained an economic embargo against Cuba for many years until just this year, never forgiving it for turning to the Soviet Union after the Cuban revolution of 1959. Fidel Castro, its leader of 49 years at his retirement in 2008, was a firebrand revolutionary and anti-capitalist who aroused the great ire of many right-wing Americans as well as of the substantial population of Cuban exiles living in America. He never missed an opportunity to thumb the nose of his arch enemies.

Economically the Cuban economy has been heavily affected by decades-long sanctions imposed by the USA. Despite this, Cuba has scored some notable successes on the world stage: its sportsmen have competed successfully in many different disciplines; during the Cold War its soldiers acquired

a formidable reputation as they inspired and aided revolutionary movements, including those fighting against imperialist and racist white regimes in South Africa, Zimbabwe and Angola. Under Fidel Castro, and to a lesser extent now his brother Raul, the Cuban State is fiercely ideologically driven, and motivated to a large extent by principle rather than material reward.


Nothing demonstrates the Cuban enigma more than the field of medicine, where Cuban success has been as great as in any other. According to WHO statistics, Cuba has one of the highest doctor/citizen ratios in the world. The country has extensive medical training facilities and not only trains more medical workers than it needs domestically, it also provides extensive training for foreign students. In its Latin American School of Medicine (ELAM), Cuba provides free medical training for some 20,000 students from around the world. Whenever a major disaster strikes around the world, Cuba, with an army of doctors at its disposal, invariably stands ready to send in a large medical team. Whether it be Ebola in West Africa, an earthquake in Haiti (2010), Hurricane Katrina in the USA (2005), or the Kashmir earthquake in Pakistan (2005), the Cuban government offers its medical expertise. "They are always the first to arrive and the last to leave," UN Secretary-General Ban Ki-moon has said of Cuban medical deployments. "They remain in place after the crises. Cuba can be proud of its healthcare system, a model for many countries."


Domestically, Cuba provides free or heavily subsidized medical services to all its people. The WHO's Director-General, Margaret Chan, visited Cuba in 2014 and praised the organization of its domestic medical facilities.  In 2015, Cuba became the first country to eradicate mother-to-child transmission of HIV and syphilis, a milestone hailed by WHO's Margaret Chan as "one of the greatest public health achievements possible". The public health approach is different from that of the West, focusing on preventive rather than curative care, and centered on the family clinic, present in every neighbourhood. Regular visits are paid by physicians to homes in the community, a practice long phased out in Western for-profit medicine. In Western private medicine, maximisation of profit is certainly one of the objectives, whereas in the Cuban system it seems fair to say that optimisation of health outcomes has a higher priority. The Cubans have managed to achieve health indicators comparable to those in the West at a far lower cost than their Western counterparts. Life expectancy is 78.3 years, comparable to that in the USA. 2012 infant mortality was 4.8 deaths per 1000 live births compared to 6.0 in the US. In 1999 Cuba had on average 58.2 doctors per 10000 population. The ratio is reported to have increased since then. For comparison, in Sierra Leone the figure is approximately 0.3 doctors per 10000 population (assuming, perhaps generously, 200 doctors for a 6 million population). Whilst the West achieves good health indicators by huge absolute spending on health care, Cuba, a much poorer country (GDP per capita, $6985) achieves its results by a more efficient allocation of funds, and a rigid belief, apparently widely shared within its medical community, that medical care is not the arena in which to make large profits. It would be interesting to find out how much and what type of ideological training is given to medical students in Cuba during their training. There have been rumours in the West of coercion and intimidation of medical staff, but it is difficult to imagine how a medical system of this size and quality could operate successfully over such a long period without an overwhelming core of genuinely dedicated staff. On the other hand, too, one cannot dismiss the argument that Western systems also provide indoctrination, albeit perhaps in a less structured way, of the belief that medicine should be an area of high profit. One could also argue convincingly that in order to provide medical services to the poorer sections of society, a thoroughly worthwhile goal, a certain amount of indoctrination of medical personnel might be no bad thing. If we in Sierra Leone had had a stronger medical presence in the poor, remote areas of the country where Ebola began, we might have avoided catastrophe.
 

Even as doctors in America, just 100 miles away, earn stratospheric salaries and private medicine earns astronomical profits, the Cuban government has prevailed for decades in Cuba with the idea that medical care is an essential social service that must be made readily available to its people; that medical workers are workers more or less like any others and should not command exceptional benefits. The system has managed to retain a large, qualified workforce in the face of overwhelming temptation elsewhere partly, yes, by strict controls on emigration, but partly also by the strength of its ideology. There are few adversarial systems that Western capital has been unable to break down, but the Cuban medical system has operated for decades apparently impervious to the allure of Western for-profit medicine. With the new rapprochement with Washington bringing unrestricted travel and communication it should be interesting to see whether the Cuban state can continue to maintain a system out of step with much of the rest of the world.

The conundrum of Cuba is that everywhere else in the world, even perhaps in Communist China, the ideological debate appears to be over. With the Cuban medical system the debate resurrects, and the socialists appear to have a good case. Obamacare in America, President Obama's initiative to extend health insurance to the poorest of Americans, fiercely contested still by right wing conservatives, is an acknowledgement that private medicine leaves large numbers in society deprived of quality health care. This of course Europe, with its more extensive social security programs, has recognized for decades. But even in European countries, the public health service is widely regarded as inferior to private medicine. Cuba provides the counter example. It says, we won't allow private medicine, but we will maintain a public service that provides as good or better service at a fraction of the cost. The opponents of socialized medicine around the world are numerous and vocal, but they are hardly disinterested. Huge industries in the West, pharmaceutical, hospital, medical insurance, among others, along with prosperous medical practitioners,  would be threatened if the Cuban model came to be seen by society as the more effective. This is true not only in the West, but all across the Third World where private medicine has taken hold. Clearly, there are very powerful, worldwide constituencies that would NOT like the Cuban medical system to be seen as a shining success.

Should an engineer earn more than a train driver? Why? And if so how much more? Should an accountant earn more than a teacher? Why? And if so how much more? How much should a doctor earn? The answers to these questions are partly cultural. Societies around the world have devised different answers to them. Many of the answers are based, even if loosely, on the laws of supply and demand and market forces. How much money does an engineer generate, compared to a train driver? How many engineers does society have, compared to train drivers? How easy is it to train an engineer, compared to a train driver?  However, for certain professions (and medicine springs most readily to mind) the approach of market forces breaks down. Because it leads to the conclusion that if you have no money you should receive no medical treatment, and if you only have a little money you should receive only a little medical treatment, and most societies find this position unacceptable.

The Cuban medical system is unsettling and threatening to adherents of private medicine because it turns our assumptions and expectations upside down. We expect mass defections of Cuban medics to private medicine outside Cuba, but it hasn't happened.The behaviour we learn of in Cuba is starkly different from the behaviour we know all about us, from which many assume malfeasance. Cuba's medical programs appear to be expanding over the years, not declining as communism has declined. ELAM, the Latin American school of Medicine that trains students without charge from all over the Third World, was founded in 1998 and graduated its first batch of 1,498 in 2005.  In 2013 it reportedly had an enrolment of 19550  including a number of scholarship holders from its archrival, the USA.

To return finally to our own small corner of the globe, the three Mano River countries have just undergone a catastrophic health emergency that has exposed and decimated their health systems. What better time than this could there be to launch a program to resuscitate medicine here? What better way could there be than an approach to Cuba for special access to its ELAM school of medicine, which is already training thousands of students at no charge. A fast-track program to train one or two thousand doctors from Sierra Leone, Liberia and Guinea would make a huge difference to the availability of medical personnel in the region and should significantly improve health outcomes. In order to obtain sufficient local candidates for admission to ELAM over the next few years judicious investment in the secondary school systems from our governments would be required: scholarships and allowances at SSS (we had these in the sixties and seventies) for science students, special incentives for science teachers, investment in science textbooks, laboratory equipment etc. All these would boost our secondary school science output and enable us to provide enough candidates for ELAM to make a real difference to our health personnel base. What better time to approach a presumably still-sympathetic Cuban government than now?