OPINION: As World Bank learnt valuable health lessons from Cuba, so too can SA
JOHANNESBURG - The current debate on the medical role and cost of the Cuban Health Brigade in combating the Covid-19 pandemic has exposed the fault lines of inequality in our society and also the limits of our consciousness on social solidarity. Praise for Cuban health expertise and its value for preserving human life is long standing. It has also come from the unlikeliest of quarters.
"Cuba has done a great job on education and health, and it does not embarrass me to admit it. They should be congratulated on what they have done," said James Wolfensohn, the former president of the World Bank in 2001 at the launch of the Bank’s World Development Indicators report.
The Bank’s report demonstrated that Cuba exceeded all developing countries in its health and education outcomes that year and matched many developed countries who had more than three times the resources of the small island nation. With very minimal resources compared to developed countries, Cuba has achieved similar or better health and education outcomes.
Wolfensohn, rather than clinging to the failed ideologically driven polices of the Bank, was persuaded by the hard evidence of Cuba’s successful achievements in health and education. He acknowledged the valuable lessons this had for the world and the need to learn from Cuba. The lessons of Cuban successes in public health care are all the more valuable now as we seek solutions to the devastating Covid-19 pandemic. Italy has now welcomed a second medical brigade from Cuba to assist in curbing its devastating pandemic.
South Africa's lack of resources
In South Africa, with the commencement of our fourth stage lockdown the infection rate is rising rapidly.
There are a recorded 7220 infections, tragically with 138 deaths as of May 4. The Eastern Cape government has already requested medical expertise to deal with its shortages in medical personnel.
Currently 34 percent of the population, or 19 million people, are located in under-resourced rural areas. Yet, only 15 percent of our doctors and 20 percent of nurses are located in those areas according to Rural Doctors Association of Southern Africa (Rudasa) chair, Dr Lungile Hobe-Nxumalo.
He describes the situation as “chronic”. Who will provide health services to these rural communities under the potentially cataclysmic health conditions caused by the Covid-19 pandemic and alongside the deeply committed medical personnel of Rudasa?
The South African Medical Association, which represents private sector doctors, have protested against guidelines issued by the Health Professions Council of South Africa on the use of telemedicine during the Covid-19 pandemic.
These private sector doctors wish to avoid direct contact with patients who may be infected with Covid-19. They argue for telemedicine as the primary interface with patients. How will this be sustainable logistically and practically under emergency conditions in poor, rural and marginal urban environments with a possible mass demand for medical care? This is not a request the Cuban Medical Brigade are making: interfacing directly with patients with appropriate personal protection equipment is part of their high-level training and among the risks they have volunteered for. Their professional orientation and preparedness stems from a qualitatively different impulse of human solidarity, a choice they have made as volunteers for Cuba’s international health missions. They fully appreciate the risks and their responsibilities to their patients as has been demonstrated in the 60 years of international medical service they have provided under adverse conditions.
World class expertise
The issue should not, therefore, be polarised between support for appropriately trained South African medical doctors, who have now been requested to apply for unfilled posts by Health Minister Dr Zweli Mkhize, and drawing on the expertise of the Cuban Medical Brigade. Maybe, in the words of globally acclaimed epidemiologist and infectious diseases specialist Professor Salim Abdool Karim, we will find a ‘mojo’ that magically protects us from the worst effects of the pandemic. In the meantime, while we correctly raise questions on an informed basis backed by expertise, we would nonetheless be wise to support the efforts of our government to fully prepare for the worst.
We need to draw on and learn from the best available global expertise on public health care under emergency and disaster conditions. If prestigious global awards are an indicator, then Cuba is undeniably the country with such world class expertise.
In 2017 the Dr Lee Jong-wook Memorial Prize for Public Health was awarded to the 7 400 voluntary Cuban health workers of the Henry Reeve International Medical Brigade at the World Health Assembly that year. The award was made to the Brigade for treating 3.5 million people in 21 countries afflicted by the worst natural disasters and epidemics in the preceding ten years. 80 000 lives were saved as a consequence of the Brigades emergency medical interventions. Why do some commentators seem to object to us drawing expeditiously on this world leading Cuban medical and planning expertise under emergency and disaster conditions?
SA's unequal healthcare system
Especially, since the pandemic, if it is not effectively curtailed, could have devastating effects on those who continue to be poor, hungry, unemployed, and marginalised in democratic South Africa.
Impoverished South Africans who, moreover do not have access to our deeply unequal private health care system and are reliant on public health care. As is their right, some commentators are questioning the role and cost of the Brigade.
Ironically they form part of the privileged 16 percent of our South African population who have exclusive access to our private health care system that consumes 50 percent of our total annual health spending. Why are there no trenchant questions being asked also about the many billions of rand being spent exclusively in the private health care sector and who will be the primary beneficiaries of this spending and resources in this time of an impending national crisis ?
Where also are the voices of the other 84 percent of our poorer citizens who are not served by this unequal system of private health care, but will likely benefit most from the Brigade? The key point is that the expertise the Cuban Medical Brigade draws on represents an unparalleled 60 years of cumulative experience of public health medicine in the worstem ergency and disaster situations in the world.
A mere six months after the Cuban social revolution in 1959 the island despatched a medical team to assist the thousands injured and millions rendered homeless in a Chile devastated by an earthquake that year. In 1963 another team of medical personnel was sent to newly independent Algeria to help rebuild the public health care system eviscerated by the struggle of Algerians for liberation from brutal French colonialism.Cuban international health expertise extended since the 1960’s to include 164 countries.
Many of these countries, like the Ukraine, which experienced the disastrous Chernobyl nuclear disaster in 1986, were unable to re-imburse Cuba yet the country still provided medical care and rehabilitation services for the more than 25 000 Ukrainians over many years - mainly children with severe injuries and cancer related conditions.
The medicines that the Cuban health care system provided was estimated alone as worth $350 million (R6.5 billion).
Dr Julio Medina, general co-ordinator of the Chernobyl programme pithily expressed the underlying principle which informed Cuban solidarity, "It is simple: we do not give what we have in excess; we share all that we have." Reimbursement only follows the ability of the country to re-imburse Cuba for its service: assistance is not conditional on such payment being made beforehand. Yes, Cuba sends its medical brigades to the worst emergency situations at the request of governments and is reimbursed. Those funds are re-invested in its health and education systems and help to sustain Cuba’s universal systems of provision for its people. In contrast, in 2014 the US Pentagon assigned $285bn to federal contracts. Approximately 45 percent were for ‘services’, including private military contractors (mercenaries, more accurately) to fight in the global wars of the US.
Cuba places its very minimal financial resources into training an army of ‘white coats’ to benefit the health of the most impoverished globally, while the US invests immeasurably greater resources in private armies that ultimately kill people in countries that the US does not like for usually self-serving reasons.
For we South African’s, who live in a country that still has amongst the worst level of inequality in the world and which is expressed in our social cynicism and informs the quality of our collective consciousness, solidaristically motivated societies like Cuba seems entirely inexplicable. Societies in other words that do not define human life in terms of profit and cost motives are a novelty, judging by some recent media articles.
According to the United Nations, the US embargo has cost Cuba $130bn by 2018, with immensely damaging human and developmental consequences for the country. The Cuban social achievements praised by the ex-head of the World Bank are thus all the more remarkable as it has been achieved with one hand tied behind its back.
Developmental purpose/ social solidarity
South Africa also has many committed social groups and exceptional individuals organised around the concept of social solidarity, including in this period of the Covid-19 pandemic. However, this is yet to translate into a societal social solidarity that unites all social groups behind a commonly shared developmental purpose of the kind found in Cuba and some of the Nordic countries.
Our deep inequality and poor developmental decisions, such as uncritically adopting the neo-liberal GEAR policy framework, has reinforced racialised class fractures in our society that militate against social solidarity. The impoverished bear the brunt of this failure. Through many years of research and travel to Cuba as a scholar of their culture of solidarity and its lessons for Southern Africa, I have, alongside colleagues from Angola, Mozambique and South Africa sought to understand the spirit and tenacity of Cuban internationalism. Why are volunteer Cuban international activists in health and education the first to support impoverished people in the most abysmal of emergency, disaster and oppressive situations in the developing world? What is the motivating force ?
This can’t be explained, as some cynics will do, by compulsion. Humans do not perform optimally and with focus, vigour and commitment in dire emergency situations if forced and not in the way the first arriving Cuban medical brigade did in helping to combating the lethal Ebola virus epidemic in West Africa in 2014.
The concept that explains the Cuban social solidarity is best encapsulated in the Spanish term 'y dignidad'. Dignity. This concept represents for me the meaning of Cuba’s modern revolution that triumphed in 1959. Not on our knees and not as slaves: dignity not only for ourselves but all societies experiencing hardship and oppression.
Under the most adverse and hostile conditions of intense US imperialist aggression, since 1960 the Cuban people have triumphed because they have not been willing to sacrifice their dignity as an emancipated people, their freedom to choose and decide their own destiny as a nation.
Cuban’s see the defence of their own hard-won dignity as unequivocally linked to the dignity of other poor nations. It is written into the country’s Constitution: ‘internationalism, fraternal friendship, help, cooperation, and solidarity of the peoples of the world’. It has become embedded in the Cuban psyche.
It is also illustrated in the words of a Cuban academic colleague, Dr Ileana Sorolla, with reference to the Battle of Cuite Cuenvale in Angola in 1987, where Cuban volunteer forces were decisive in assisting the Angolan government to repel a second invasion by the apartheid army.
She said, "I think you do not fully understand. My generation of Cubans in the mid-1970’s were as much influenced within Cuba by the defence of the people of Angola as what you were inspired in South Africa by Cuba while struggling against apartheid. We discussed this every day. Africa and the victory and success of its people became very dear to us as a nation."
SA ties to Cuba
Nelson Mandela said on his first visit to Cuba: "We have come here today recognising our great debt to the Cuban people. What other country has such a history of selfless behaviour as Cuba has shown for the people of Africa? How many countries benefit from Cuban health care professionals and educators? How many of these volunteers are now in Africa? What country has ever needed help from Cuba and has not received it?"
So Cuba is no new, fair weather friend of South Africa. It does not extract from us and boss us around like some of our so-called Northern partners do. Cuba supported us in the very worst of times under apartheid. It trains thousands of South African doctors in public health medicine, almost all of them from poor communities.
Cuba is supporting us again, in our worst of times. The questioning of the Cuban Medical Brigade reveals some people’s priorities and exposes our fault lines. Where are our medical brigades of South African medical professionals, skilled, prepared and ready to serve in the most impoverished areas of our country?
Sadly, it seems that many of our medical personnel, old and new, are too busy enriching themselves in private practice in the safety of comfortable urban suburbs. Many of them display on currently available evidence no aspiration or intention to avail their medical expertise to directly serve our people in the rural and most impoverished areas where they will be most needed.
If the Cuban Medical Brigade’s expertise by contrast can save the lives of impoverished people in the most marginal communities, that will be an incalculable and welcome benefit for our society. The discussion on the volunteer Cuban Medical Brigade is holding up a mirror to the depths and limitations of our social solidarity as South Africans – our real challenge as a society is whether we learn from what we see reflected back at us, as the Covid-19 pandemic steadily encroaches.
Robert Van Niekerk is professor and the Chair of Public Governance at the Wits School of Governance. His current research projects focuses on the history of social policy (in particular health policy) and universalism in South Africa and black intellectuals, inequality and social democratic thought. He co-leads a project with academics from Cuba, Angola, Mozambique and South Africa on “Cultures of Social Solidarity and the Public Good: Reflections on South Africa and Cuba”.
Robert Van Niekerk