Cuba, New Zealand and doctors for the Pacific

Medical co-operation has been a well-known part of Cuba’s foreign policy for over five decades. What is less known is that country’s commitment to training doctors for the world, the reach of this programme into the Pacific and New Zealand’s involvement in the programme. Cuba’s connections in this part of the world, including the presence of Cuban doctors, has developed steadily in the last two decades. With a shared commitment to addressing healthcare challenges in the Pacific region, New Zealand has connected with this programme, addressing the key challenges inherent in bringing Cuban and Cuban-trained doctors to the region.

In 2017 a panel of Latin American diplomats assembled at the Latin American studies conference at Victoria University of Wellington. Asked to speak about connections between their nations and the Pacific region, most focused on trade and tourism opportunities. The final speaker was Mario Alzugaray, the Cuban ambassador to New Zealand at the time. Alzugaray raised a laugh with his claim to difference. His job, he said, was cigars and doctors.

Cuba’s legendary (and sometimes controversial) doctors are well known. Hundreds of thousands of Cuban doctors have served in Latin America and Africa in the five decades since the revolution. What is less known is Cuba’s commitment to training doctors for the world, and the reach of this programme into the Pacific. Over the past decade this co-operation has contributed to a doubling or more of doctor numbers in some countries in the region, including an increase in the total number of doctors in Kiribati from eighteen to 51. Remarkable increases have also been recorded in the Solomon Islands (79 to 170), Tonga (44 to 80), Vanuatu (27 to 67) and Tuvalu (seven to 27).

This article will provide some background to Cuban medical internationalism and the presence of Cuban doctors in the region, before exploring the ways in which New Zealand has connected with and contributed to this programme.

Cuban internationalism

Sharon McLennan is a senior lecturer in development studies at Massey University. She has teaching and research interests in critical and decolonial approaches to development, global citizenship and global health, and has a background in nursing and international volunteering.

Co-operation in health has been an essential component of Cuba’s foreign policy for more than five decades, and Cuban doctors, particularly those associated with the Henry Reeve International Medical Brigade, engage in a variety of activities aimed at providing healthcare services and expertise to countries in need. While this co-operation is most visible during crisis events, much of the work is usually directed towards long-term public and primary health care. This focus is particularly significant. It is based on the values of solidarity, equity and the right to health, and on Cuba’s experience building a relatively well performing health system that provides Cubans with better access to healthcare and longer life expectancies than those in many developed countries.1

Up until 1999 Cuban medical co-operation was largely focused on sending Cuban health professionals to serve in other nations. But Cuba has also recognised that having foreign doctors staff health systems indefinitely is unsustainable, and that ‘the ideal provider is a well-trained, homegrown health professional’.² To address this Cuba created medical scholarships for international students. Recipients study for six years at the Latin American School of Medicine (ELAM) in Cuba for free under the agreement that upon completion of their studies they return home to serve their communities. The purpose of the ELAM is, therefore, to train students from lower income and medically under-resourced communities who will go on to serve their countries.

Cuba’s commitment to universal health care and recognition of the value of primary care is deeply embedded in the education provided by the ELAM, ‘providing hands-on learning about social determinants’ effects on health; sharing responsibility for addressing spatial inequalities and delivering equitable, accessible services; going beyond pedagogical innovations to include integration of graduates into local health systems’.³

From the beginning, the ELAM’s goals reflected Cuba’s commitment to solidarity, internationalism and sustainable development, with programmes that aimed to build health care capacity in countries around the globe, educating doctors primarily for public service who have competencies in comprehensive primary care.4 While Cuban brigades continue to offer support, the scholarship programme is viewed as more empowering to local communities, and better equipped to serve their long-term needs.

Cuban assistance

The first nation in the wider Pacific region to receive Cuban assistance was the newly independent nation of East Timor. Over a decade Cuba trained nearly 1000 doctors at the ELAM and deployed 300 Cuban doctors to provide medical care and to supervise and further train students and new doctors. This programme spread across the South Pacific, with approximately 50 Cuban doctors serving in Kiribati, Nauru, Solomon Islands, Tuvalu and Vanuatu between 1999 and 2017, including specialists in oncology, nephrology, psychiatry, endocrinology, internal medicine and others — many of whom were the only such specialists in country at that time.⁵

In addition, between 2014 and 2023 over 250 students from the Pacific were given scholarships to study in Cuba, including Cook Islands (one), Fiji (34), Kiribati (38), Micronesia (one), Nauru (four), Palau (seven), Solomon Islands (109), Tonga (fourteen), Tuvalu (21) and Vanuatu (25). As these newly trained doctors have returned home over the past decade the impact has been significant. Data presented at the thirteenth Pacific Health Ministers’ Meeting in 2019 shows a significant increase in the number of doctors employed by several Pacific ministries of health, including, as noted, a doubling of the number of doctors in Solomon Islands, Kiribati and Vanuatu.⁶ While there are no official reports on the impact of the Cuban programme and improvements cannot be solely linked to the Cuban programme, many key health statistics have continued to improve across the region.

Qualitatively, there have been some notable improvements in health delivery with the return of the Cuban-trained doctors. For example, early in the programme, Cuban-trained doctors were identified as a driver in the strengthening of Kiribati’s health system,⁷ enabling doctors to spend more time with patients and deliver higher value care. This improvement was also seen by staff at Tungaru Central Hospital in Tarawa, Kiribati, where staff noted that since the beginning of the Cuban programme the number of departments at the hospital that had a full team (nurse, medical intern, registrar, specialist) had increased and the ability of the hospital to respond more promptly to afterhours medical care and emergency situations had improved.⁸

In addition to training doctors, Cuba provides support for health more generally. This includes high-level support as a dialogue partner of the Pacific Islands Forum (PIF), which was reiterated at the recent 52nd PIF Leaders’ Meeting in the Cook Islands where Cuba reasserted its commitment to friendship and co-operation, and support for the PIF Strategy 2050. Cuba also offers scientific and medical advice and support. This includes hosting a virtual meeting between Cuban and Pacific officials and health specialists during the pandemic to share experiences and knowledge in the fight against Covid-19, collaboration with Solomon Islands researchers on medicinal plants and a willingness to work with Pacific Islands and partner states to create a regional centre for the treatment of diabetes, which would draw on Cuba’s successful development and use of Heberprot P for the treatment of diabetic foot ulcers.

Diplomatic relationship

The relationship between New Zealand and Cuba dates back to the mid-20th century, a period marked by the global geopolitical shifts of the Cold War. Despite their geographical separation and differing political ideologies — New Zealand being a staunch advocate of Western liberal democracy and Cuba embracing socialism under Fidel Castro — the two nations established diplomatic ties in 1972. This historic decision set the stage for a relationship that has weathered the challenges of ideological differences and persisted through the decades.

In recent years, alongside trade (including the importation of cigars and rum), New Zealand’s relationship with Cuba has included diplomatic engagement, cultural exchanges and cooperation in various areas such as healthcare, education and agriculture. New Zealand’s involvement in supporting Cuba’s programme to train doctors for Pacific Islands nations has been an important part of this, reflecting a shared commitment to addressing healthcare challenges in the Pacific region. New Zealand’s support for this programme addressed some of the key challenges inherent in bringing Cuban and Cuban-trained doctors to the region and includes direct co-operation through language training for Cuban doctors en route to work in Pacific nations, and less direct support to assist the integration of Pacific doctors trained in Cuba and elsewhere into practice.

Language training

While the provision of doctors is an important contribution to health in the region, Cuba is a Spanish-speaking country, and this creates a language barrier between Cuban doctors and Pacific health workers and communities. To help bridge this barrier, for many years New Zealand supported language training for Cuban doctors, with programmes for Cuban doctors provided by the Bay of Plenty English School.⁹ This began in February 2015 when Craig Hawke, acting chief executive of New Zealand’s Ministry of Foreign Affairs and Trade, and Cuban Ambassador María del Carmen Herrera Caseiro signed a co-operation arrangement, in which New Zealand agreed to fund and provide an eighteen-week English language training course for up to fif- teen Cuban doctors, and to pay for the airfares of those doctors from Cuba to New Zealand and onwards to the islands when they finished the training course. At the time, Hawke called the agreement a significant milestone in New Zealand’s relationship with Cuba, and a practical, tangible piece of co-operation.10

This programme was renewed in 2017 for a further three years during a visit by then Minister of Foreign Affairs Gerry Brownlee to Cuba. In signing the renewal, Brownlee noted that since 2015 the arrangement had delivered positive results in the Pacific and emphasised New Zealand and Cuba’s shared interest in the Pacific and an on-going commitment to small islands developing states.11

Key role

New Zealand has also had an indirect but key role in addressing another major challenge, this time for Cuban-trained Pacific Islands doctors and their home countries — the need to complete internships before they could be licensed and practice independently as doctors. Previously medical graduates from across the Pacific had completed internships through the Fiji School of Medicine. However, at the same time that the first cohort of Cuban-trained doctors were due to return to Kiribati, the Fiji National University closed its internship programmes to applicants from non-Fijian medical schools.12 This created a major problem for smaller Pacific states as it came at a time when new actors were increasingly diversifying the training of Pacific students. In addition to Cuba’s ELAM, this included I-Shou University (Taiwan), Oceania University of Medicine (Samoa) and to a lesser extent institutions from Russia, Morocco, China and elsewhere.

Kiribati was one of the first Pacific states to welcome home a significant cohort of Cuban-trained medical graduates and needed an internship training programme fast. The Kiribati Internship Training Programme (KITP) was a creative strategy launched primarily in response to the return of the Cuban graduates.13 This was implemented by the Kiribati Ministry of Health and Medical Services with technical guidance from Fiji National University, the Australian Department of Foreign Affairs and Trade (DFAT) and the World Health Organisation. While initially funded by Australia through DFAT and managed by Fiji National University, from 2017 to 2019 the KITP was supported through a bilateral agreement with New Zealand. The aim of the two-year programme was to facilitate the integration of foreign-trained medical graduates into Kiribati’s health system and to establish a pathway to full qualification so they can work as medical professionals.

The future

While New Zealand’s role in Cuba’s programme to provide doctors to the Pacific has not been large, it has been significant, providing support and assistance to help Pacific nations take advantage of Cuba’s doctors and medical training. The key role played by New Zealand as trilateral partner in the KITP and language programmes alongside MFAT’s emphasis on primary and universal health care14 — areas in which Cuba has particular expertise — indicates that there is room for co-operation that aims to not only provide curative services to Pacific people but also prevent illness in the first place.

This potential is evident in meetings between the Cuban ambassador and Māori leaders over the past three years. In 2020, the ambassador was gifted a Māori taonga made by royal carvers from the jaws of the whale that they had used to carve Kiingi Tuheitia a baton, symbolising his aspirations of future relations.

This was followed up with a meeting with iwi leader Tuku Morgan and other community leaders in September 2022 at Te Ohaaki Marae, where future co-operation, particularly in the field of health was discussed. In a private audience with Kiingi Tuheitia in October 2023, Cuba reiterated this support, stating Māori can ‘count on Cuba’.15

There is also potential for collaboration in biotech, including vaccine development. Despite the on-going US embargo, which makes access to supplies and equipment an on-going struggle, Cuba has an innovative and highly successful biotech sector, and was able to quickly develop effective Covid-19 vaccines, and to subsequently vaccinate a large portion (more than 90 per cent) of its population.16 In addition to vaccinating its own citizens, Cuba demonstrated its global solidarity through exports of vaccines and vaccine production technology.17

There has been considerable interest in New Zealand in Cuba’s model for vaccine development, and New Zealand has previously drawn on the work of Cuban researchers in the MeNZB meningococcal group B vaccine used in New Zealand between 2004 and 2011. In 2023 Cuban chemical research scientist Marianniz Díaz Hernández met with officials from Auckland’s Te Whānau o Waipaeira Trust, MFAT and the University of Auckland’s School of Medicine to discuss the experience of her country’s biotech industry and vaccine development.18 As Dr Nikki Turner, medical director of Auckland University’s Immunisation Advisory Centre, noted in an article in the New Zealand Doctor website:

Being fully government funded, Cuba’s biotech sector isn’t compromised by corporate interests and the work researchers undertake isn’t ‘siloed off’… [which] means you can put more of an equity lens on things and look at what the population actually needs. Whereas when you have large multinationals involved, their focus is often on where they can make a profit.19

While Cuba–New Zealand co-operation is relatively small, past, present and potential future collaborations with Cuba in health are significant. The co-operative effort in providing doctors for the Pacific underscores New Zealand’s commitment to enhancing healthcare capacity in the region, leveraging the expertise and resources of both nations. The exchange involves not only the provision of medical education but also the cultivation of a diverse and culturally sensitive healthcare workforce, and demonstrates how international partnerships can play a crucial role in addressing the unique challenges faced by Pacific Islands nations in terms of healthcare access and delivery. While the future of this co-operation under the current coalition government is unclear, there is considerable potential for Cuba to contribute to building a more resilient and sustainable healthcare infrastructure in the Pacific and here in New Zealand, forging bonds that extend beyond national borders for the betterment of the entire region.

Notes

1. Carissa F. Etienne, ‘Cuba aims for Universal Health’, Pan American Journal of Public Health, vol 42, no 64 (2018), pp.1–2 (doi. org/10.26633/RPSP.2018.64); PAHO, ‘Country Profile: Cuba’ (2021)

(hia.paho.org/en/countries-2022/cuba-country-profile).

2. Conner Gorry, ‘Six Decades of Cuban Global Health Cooperation’, MEDICC Review, vol 21, no 4 (2019), p.86.

3. Ibid.

4. Sharon McLennan, Robert Huish and Christine Werle, ‘The gift of health: Cuba’s development assistance in the Pacific’, The Pacific Review, vol 35, no 1 (2022), pp.90–115 (doi.org/10.1080/09512748 .2020.1808053); Yoandra Muro Valle, Heidy CantilloVento, Mirvia Espino Suárez, Raúl Urquiaga Rodríguez, ‘La internacionalización en la ELAM: origen y vigencia’, Convención de Salud (2022) (con vencionsalud.sld.cu/index.php/convencionsalud22/2022/paper/ viewFile/2718/1268).

5. Felipe Delgado Bustillo, ‘Unidad Central de Cooperación Médica: Anuario 2017’, UCCM (2017); McLennan, Huish and Werle, pp.90–115.

6. Sharon McLennan and Christine Werle, ‘We are the ones who will have to make the change: Cuban health cooperation and the integration of Cuban medical graduates into practice in the Pacific’, Human Resources for Health, vol 21, no 36 (2023) (doi.org/10.1186/ s12960-023-00822-8); WHO, ‘Health workforce development in the Pacific — A deep dive into the Pacific Medical Workforce’, Thirteenth Pacific Health Ministers Meeting (www.who.int/westernpa cific/about/how-we-work/pacific-support/pacific-health-ministersmeetings).

7. Representaciones diplomáticas de Cuba en el exterior, ‘Minister for Local Government expresses appreciation for Cuba’s cooperation in the Pacific region’ (2016) (misiones.minrex.gob.cu/en/articulo/ minister-local-government-expresses-appreciation-cubas-coopera tion-pacific-region, acc 27 Jan 2017).

8. Sharon McLennan, Helen Leslie and Christine Werle, ‘The gift of health: Cuban medical cooperation in Kiribati’, Pacific Dynamics: Journal of Interdisciplinary Research, vol 7, no 1 (2023).

9. Representaciones diplomáticas de Cuba en el exterior, ‘Cuban doctors complete English training program in New Zealand’, 11 Apr 2017 (misiones.cubaminrex.cu/en/articulo/cuban-doctors-completeenglish-training-program-new-zealand).

10. RNZ Pacific, ‘NZ to help Cuban doctors with English’, 19 Feb 2015 (www. rnz.co.nz/international/pacific-news/266539/nz-to-help-cuban-doc tors-with-english).

11. Gerry Brownlee, ‘NZ to support training of Cuban doctors’, 29 Jun 2017 (www.beehive.govt.nz/release/nz-support-training-cuban-doc tors).

12. Rob Condon, Robbert J. Duvivier, Revite Kirition, Kafoa Berlin, Judy McKimm and Graham Roberts, ‘Medical internship programs in the Pacific: Current situation and future challenges’, Human Resources for Health Knowledge (Sydney, 2013).

13. Jemesa Tudravu and Graham Roberts, Independent External Review: Kiribati Medical Internship Training Program (KITP) (2019).

14. MFAT, ‘Pacific Regional Four Year Plan’, Oct 2021 (www.mfat.govt.nz/ en/countries-and-regions/australia-and-pacific/).

15. Representaciones Diplomáticas de Cuba en el Exterior, ‘Maori king receives the Cuban ambassador’, 24 Oct 2023 (misiones.cubaminrex.cu/en/articulo/maori-king-receives-cuban-ambassador).

16. Sandro Galea and Paul C. Erwin, ‘Improving the US and Global Pandemic Response: Lessons From Cuba’, American Journal of Public Health, vol 113, no 4 (2023), pp.361–3.

17. Achal Prabhala and Victor Ido, ‘Next pandemic, let Cuba vaccinate the world’, Washington Post, 1 Jun 2023; Mitchell Valdés-Sosa, ‘Despite U.S. Embargo, Cuba Aims to Share Homegrown Vaccine with Global South’, Democracy Now, 27 Jan 2022 (www.democracynow. org/2022/1/27/cuba_beat_covid_despite_us_embargo).

18. Stephen Forbes, ‘Still under sanctions, Cuba punches above its weight in biotech’, New Zealand Doctor, 4 Aug 2023 (www.nzdoc tor.co.nz/article/news/still-under-sanctions-cuba-punches-aboveits-weight-biotech).

19. Ian Powell, ‘Cuban Health System Lessons’, Scoop, 2 Sep 2023 (www.scoop.co.nz/stories/HL2309/S00002/cuban-health-systemlessons.htm).