South Africa’s cabinet will be proposing the Contingente Internacional de médicos especializados en situaciones de desastre y graves epidemias ‘Henry Reeve’ – the Cuban ‘medical brigade’ deployed to assist other countries facing medical disaster situations – for the Nobel Peace Prize. While largely symbolic, this is a very visible and audible gesture from South Africa’s government towards not only Cuba’s medics, but towards the Cuban state as a whole. And, like practically all things Cuban in South Africa, this has received an outsized reaction.
‘My heart is in Havana’, goes the refrain in the popular 2017 song by Camila Cabello. This is a line that could easily be appropriated to reflect the emotional hold that Cuba has on millions of people around the world, more than a few in South Africa, particularly in the ruling African National Congress (ANC). Nelson Mandela visited the island nation in 1991, declaring: ‘The Cuban people hold a special place in the hearts of the people of Africa. The Cuban internationalists have made a contribution to African independence, freedom, and justice, unparalleled for its principled and selfless character.
From its earliest day, the Cuban revolution has itself been a source of inspiration to all freedom-loving peoples … We in Africa are used to being victims of countries wanting to carve up our territory or subvert our sovereignty. It is unparalleled in African history to have another people rise to the defence of one of us. We also know that this was a popular action in Cuba. We are aware that those who fought and died in Angola were only a small proportion of those who volunteered. For the Cuban people, internationalism is not merely a word but something that we have seen practised to the benefit of large sections of humankind!’
It would be hard to find a better encapsulation of the sentiment underlying the attachment that much of the country’s political and intellectual elite has to Cuba. ‘Cuba’ represents as much an idea as a country. It is avatar to many on the left of a Communist society that not only rose from backwardness, and from the shadow of a superpower, but endured even as its larger brethren collapsed or reformed. There is a quasi-mystical quality to all this. Ernesto ‘Che’ Guevara formulated the idea of a ‘New Man’, a whole new idea of being human, with a consciousness motivated by altruism and ideology. Perhaps that has meaning for the constant invocation of the ‘Cuban people’ as coterminous with the Cuban state.
For the more muscular among its admirers, Cuba embodies political machismo. Not only was its regime the product of a successful armed uprising – and defended it against an invasion – but since the 1960s it has deployed its military directly in conflicts in Angola, the Horn of Africa, Algeria and Syria, as well as Latin America. It has provided extensive military and intelligence support to friendly regimes, and was a vigorous (sometimes active) supporter of leftist insurgencies. For the ANC, the influence of Cuba’s military record cannot be overestimated. Cuban troops fought the old South African Defence Force in Angola on equal terms; its professionalism and willingness to take casualties were beyond doubt.
The Battle of Cuito Cuanavale, fought over 1987 and 1988, has entered liberation mythology as the military ‘defeat’ of the SADF. For the ANC, which waged its own largely ineffectual armed struggle for three decades, there is some reflected glory in this. (Incidentally, the outcome of Cuito Cuanavale is disputed, and claimed as a victory by all sides. A senior Russian academic, well experienced in Africa during the Cold War, once told me of his attempts to organise a conference to discuss it in the 1990s. There was very little interest, all parties apparently being quite satisfied with their own mythologies and not wanting to see them challenged. He added that the ANC had no real presence at the battle.)
Nexus between ideology and solidarity
Elizabeth Sidiropoulos, director of the SA Institute of International Affairs, says that the relationship between Cuba and South Africa can be understood as the nexus between ideology and solidarity. On the one side, there are the ties of history and politics. Many in the ANC’s leadership have spent time in Cuba, or have been steeped in its mystique.
On the other, there is a sense of a special, reciprocal relationship. Just as Cuban arms were held to have propelled South Africa towards liberation, so a duty is owed by South Africa to support that country. This is bolstered by the commitment of South African foreign policy since the 1990s to the ‘Global South’, the heterodox collection of ‘developing’ nations seeking their place in the sun, and often defined in contradistinction to the advanced capitalist democracies.
There are some interesting twists to this. While Cuba as an idea looms large in South Africa’s consciousness, Cuba as a country sits uncomfortably with South Africa’s realities. There has, for example, been very little serious analysis published on the relationship. Certainly, South Africa (and the ANC) has supported Cuba diplomatically at international fora. It has provided the island with some symbolic accolades, as when Fidel Castro was invited to address Parliament in 1998, and when his successor, Raul Castro spoke at the memorial service for Nelson Mandela. At the latter event, a handshake between Castro and US president Barack Obama marked the first fleeting contact between the heads of state of the respective countries in decades. Cuba provides a focal point of sorts for left-wing activists in South Africa, Havana as the socialist Nirvana.
South Africa’s economic relationship with Cuba is marginal. In 2018, South African exports to Cuba stood at some $1.65 million. This was exceeded even by exports to Curaçao and Belize, of whose very existence most South Africans are probably only dimly aware. (These numbers are sourced from the excellent Observatory of Economic Complexity, https://oec.world/en.) Imports from Cuba in that year amounted to some $4.45 million, 92% of which consisted of rolled tobacco and hard liquor – raising the interesting factoid that while Cuban medics were arriving in South Africa to fight COVID-19, its exports were rendered contraband.
No mean feat
Seen thus, the relationship between the two countries is not matched in substance by its emotive intensity. But Cuba has achieved – no mean feat – important strides in its human development. Attainment in education and healthcare is generally well-regarded worldwide. It has a skilled population which the Cuban state has turned into a formidable asset.
Hence its ‘medical diplomacy’. Cuba’s provision of medical services has been a key part of its brand since the 1960s. It has been presented as a selfless act by a poor, developing country for the greater good of humanity. No doubt, people who have been successfully treated by a Cuban doctor would not quibble about that. Nor should one impugn the motivations (which are probably complex) of the individual doctors participating. But for the Cuban state, the issue is more complicated.
As one sympathetic account – by American scholar Julie Feinsilver, in 2010 – put it, its medical diplomacy had a pragmatic as well as an idealistic driver. In the 1970s, Fidel Castro argued that in much of the developing world, doctors could not be found, even where hard money was available to pay for them. Cuba charged less than other suppliers (note though, this was not always free), and this had a competitive advantage. This effectively became a niche for Cuba, both bilaterally and multilaterally.
The programme tapered off somewhat as Cuba lost its Soviet sponsors in the late 1980s, although never ceasing. Agreements with South Africa were concluded in the 1990s. But the rise to power of an ideological soulmate, Hugo Chavez in Venezuela, demonstrated its possibilities.
‘Medical diplomacy has helped Cuba garner symbolic capital (goodwill, influence, and prestige) well beyond what would have been possible for a small, developing country, and it has contributed to making Cuba a player on the world stage. In recent years, medical diplomacy has been instrumental in providing considerable material capital (aid, credit, and trade), as the oil-for-doctors deals with Venezuela demonstrates. This has helped keep the revolution afloat in trying economic times.’
‘Most lucrative export’
Or, as a BBC report phrased it, ‘healthcare is Cuba’s most lucrative export’.
All well and good, but the programme has a controversial side. While a comprehensive picture of the inner workings of these programmes is elusive – given both the authoritarian nature of Cuba, and the fact that the on-the-ground operation of the medical work would be governed by bureaucratic rules that would differ from place to place – enough has come to light to raise serious concerns.
Cuba retains a tight rein on participants in the programme. This was laid out in investigations by the Spain-based rights group Prisoners Defenders among Cuban doctors who had participated in these programme and subsequently defected. Many prospective participants felt pressured into signing up, and most had no advance knowledge of where they were to be posted. One in four had their passports taken by the Cuban authorities once they arrived at their destination and nine in ten reported being monitored by Cuban security officers – and also required to report on their colleagues.
Doctors would not be able to have their families accompany them on long-duration postings, giving the state an enormous degree of leverage over them. Misbehaviour or displeasing their government (or defecting) could have serious ramifications for loved ones.
An even darker side has emerged in reports out of Venezuela. Cuban doctors were brought in to service poorer areas by the then petrocash-flush regime of Hugo Chavez in the early 2000s. As these funds have dried up and the economic folly of the past years has become ever more dire – and as the personally charismatic Chavez was replaced by Nicolas Maduro – Venezuela has turned ever more to weaponizing the means of livelihood. In this respect, Cuban doctors have reported being told not only to promote political support for the government, but to use access to medical care and equipment as a reward for its supporters and their denial as a punishment for opponents.
Less than idealism, this is the orientation of the ideologue.
Money-spinner for Cuba
Then there is the money. These programmes represent a multi-billion dollar money-spinner for Cuba. There have also been allegations that doctors are instructed by their Cuban superiors to falsify reports about their patient numbers and the treatment given so as to inflate the perception of effectiveness. This makes the case for expanding the programme.
But one of the most visible concerns is that the Cuban doctors who actually render the services are short-changed. The primary beneficiary of the payments made by host governments are not the doctors, but the Cuban state. This has been highlighted by an ongoing lawsuit in the United States by a number of Cuban doctors who are now living there. Their case, against the Pan American Health Organisation (PAHO), charged that the PAHO benefited from the ‘forced labour’ of thousands of Cuban doctors who worked in Brazil under an agreement which the organisation mediated. Of the $10 000 paid for each doctor – according to this group – the doctor received $1 000 (part of which was paid to an account in Cuba), and the rest to the Cuban state. The PAHO had received a payment for assisting in the agreement. They also allege that a battery of control measures – such as confiscating passports – was deployed against them.
It is unclear just how these abuses may have been replicated in South Africa. South Africa’s political environment is very different from that in Venezuela, and the geopolitical stakes for Cuba much higher in the Latin American country. The deployment of Cuban doctors on longer-term contracts, well publicised in the 1990s, has also declined (medical cooperation with Cuba has come to be based rather on training doctors in Cuba). An academic study of the programme, published in 2007 by British researcher Daniel Hammett, indicated that initially families were allowed to accompany participating doctors to the country, and the doctors were paid according to South African scales.
All in all, a fairly benign picture, albeit one complicated by instances of Cuban doctors trying to opt out of the programme and approaching the courts to remain in South Africa. The latter was inconvenient, since it both broke with the ideological narrative, and invoked another deeply ideological commitment for South Africa, labour legislation, in doing so.
In the case of the Henry Reeve Brigade, the question of family accompaniment is moot, since it is a disaster relief institution with a limited-time mandate. (Would a Cuban doctor want to bring spouse and children to South Africa under present circumstances?) Payment is more contentions.
The emergency workers came to South Africa at a reported cost of R430 million, according to a report in News24 in April 2020, which drew on Treasury documents. Later in the year, health minister Zweli Mkhize put the salary bill for the Cuban medics at R239 million.
Deflection and indignation
Whether this salary bill will find its way into the pockets of the medics, or the Cuban state is unclear. Queries have been greeted with a mixture of deflection and indignation. A spokesman for the health department waved away cost concerns: ‘It is not fair that anyone should focus on the price tag over the need to save lives.’ (Such rhetoric has an unfortunate habit of confirming that cost concerns are merited.)
The Cuban embassy appealed in its Facebook page to the noble traditions of solidarity and the malicious machinations of enemies. ‘This is not a commercial transaction. This is cooperation,’ it said, although a strong element of commercialism does run through its medical cooperation.
Incidentally, while medicine is Cuba’s flagship ‘cooperation’ programme, it is not the only one. In a highly controversial endeavour, the military has engaged Cuban technicians to maintain vehicles. This has been criticised for its cost, for servicing machines that should be scrapped and for ignoring the pool of South Africans who might do this work. Pikkie Greef of the SA National Defence Union described the payments to Cuba as effectively a ‘labour brokerage fee’.
Greeff may well be onto something. Describing Cuba’s programmes as ‘slavery’ or ‘forced labour’ may overstate the case. But there is certainly something in what has been alleged about them that comes close to trafficking. In the South African case, it looks remarkably like labour broking. If the state looks disapprovingly at this when it happens in the private sector, it is unconscionable to practise this itself.
Ultimately, commenting on the Cuban Medical Brigade in the Daily Maverick, Rebecca Davis summed up the issues: ‘But the government still has pressing questions to answer: about the price tag of the mission, whether the expertise offered by the Cubans could truly not be replicated locally at a lower cost, and ultimately whether the real beneficiary of the deployment is South Africa, or perhaps the cash-strapped Cuban state.’
This really is the question. The answer is ambiguous. Whatever factors motivate Cuba’s medical diplomacy (and its other cooperation), it is certainly not solely altruism. It generates very real advantages by doing so. A system of mutual aid perhaps?
This is not outlandish. South Africa is a donor of some substance, primarily in Africa, although not exclusively. Cuba itself was a recipient of a R350 million aid package in 2012. Medical and technical services provide a handy means for South Africa to assist an ideological ally with which it has few economic complementarities.
No less an act of aid is the nomination of the Cuban Brigade for the Nobel Peace Prize. This helps frame the Cuban national image and embellish its mystique. It feeds the rather distorted narrative of selflessness in the country’s actions.
Whitewashing the abuses
This might be harmless were it not effectively whitewashing the abuses of an authoritarian regime. This is not least against the ‘Cuban people’ so beloved of Cuba’s foreign admirers. ‘Let there be more generosity, more co-operation, and more humanity,’ said Fidel Castro in his address to South Africa’s Parliament. This is wise advice, and should be acted upon. Not least in the way Cuba’s friends structure their relations with it. It is past time for a critical appraisal of the Cuban state, and for a clear distinction between the state and its people to be drawn.
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