AD: Thanks for agreeing to answer a few questions about medical conditions in Cuba that might occur to someone reading your very interesting article, “Doctors for Dollars” (American Diplomacy, Autumn 1999). For a country that has taken special pride in its improvements in health conditions since Fidel Castro came to power forty years ago, Cuba doesn’t come off looking so good from your on-the-scene vantage point.

Has the progress we’ve read about elsewhere been exaggerated? Is it a matter of revolutionary fatigue or decay setting in? Or has the increased flow of dollars into Cuba served to “corrupt” the system?

Linderman: Cuba’s progress in health care over the past forty years has not been as impressive as many observers have suggested. As a 1998 report from the Bureau of Inter-American Affairs points out, Cuba’s infant mortality rate is the best in Latin America today, but it also was the best in Latin America—and the 13th lowest in the world—in pre-Castro Cuba.

In the 1990-95 period, Cuba ranked 24th in the world in this indicator. This number may still seem impressive, but the report reminds us to take Cuba’s unusually high abortion rate into account—.71 per live birth in 1991, at least twice the average rate in developed countries—since the termination of high-risk pregnancies results in lower infant mortality statistics.

Cuba places great emphasis on training doctors, resulting in a very high number of physicians per 100,000 people. However, this also continues a pre-Castro tradition. The island’s 128 doctors and dentists per 100,000 population in 1957 ranked it third in Latin America (behind only Uruguay and Argentina) and ahead of the United States, the Netherlands and the United Kingdom.

There is certainly the kind of corruption in Cuba that has flourished in any socialist state—the diversion of state-owned goods to friends and associates and, since the legalization of the dollar in 1993, increasingly to paying clients.

But the availability of medicine for dollars, in my view, points less to corruption than to the sheer impossibility of providing free health care to 11 million people out of an extremely small economic pie. Sugar, Cuba’s chief product, barely breaks even when sold at world-market prices (as opposed to the artificially-inflated barter deals offered by the Soviets). Tourism is rising, but much of the revenue is being used to construct further infrastructure. This leaves only the money sent by overseas Cubans to their families, sometimes estimated to be Cuba’s number-one source of hard currency. This should be noted with irony by Cuban-Americans who insist that the embargo remain intact.

AD: Your article describes the plight of highly trained physicians like “Dr. Eduardo” and “Dr. F” who appear to be pathetically underpaid by the Cuban system, obliged to accept dollar fees under the table from foreigners, and ultimately forced to flee the island in search of a better life abroad.

How typical do you believe their cases to be? How expensive was their medical training? What proportion of Cuba’s trained medical personnel do you suppose end up emigrating as “Dr. Eduardo” did?

Linderman: Medical training is free in Cuba, but it also holds out no promise of financial reward. Cuban doctors are paid in pesos, which have extremely little buying power on the island today. Thus, they are forced to live from hand to mouth, lining up with their ration books for beans and rice to feed their families, while others with access to dollars shop in hard-currency stores.

As one might expect, Cuba is reluctant to allow doctors to leave the country. A Cuban woman doctor who married a German businessman recently told me about the hurdles she faced in leaving the island. She had to obtain the signature of every supervisor in the clinic where she worked (from department head up to director), confirming that a replacement had been found. In addition, the exit permit required for emigration costs some $900 in hard currency and can be denied by the government. Few ordinary Cuban doctors can run this gauntlet successfully.

“Dr. Eduardo” was a very talented pediatrician and had good connections among foreigners, who assisted him in the emigration process. The question of his exit permit remained open until the end, and we were all relieved when it was granted. Perhaps the government considered him politically compromised and was thus willing to get rid of a potential dissident.

“Dr. F,” on the other hand, was not seeking to emigrate when I knew him. He occupied a prestigious position, appeared proud of his dingy hospital, and seemed willing to work within the system (which includes bending the rules at times, as when foreigners slip you twenties).

AD: It is striking that prescription medicine you sought for your gardener Pedro was unavailable generally but was available specially to foreigners and top officials at the government-run Clínica Cira García, where it was sold for dollars.

Are scarce pharmaceuticals reserved by some means for wealthier or more important Cubans and foreigners who can pay for them in hard currency? Is there similar “class privilege” or discrimination visible in hospitals or other medical facilities?

Linderman: As alluded to above, the socialist economy does not provide adequate supplies of medicine to the population as a whole. Even aspirin and similar products are unavailable. Two groups of people have access to medicine in Cuba: foreigners who pay with dollars, and top Communist Party and military officials (although even their clinic, Cimeq, experiences shortages at times).

During the so-called “Special Period” since the fall of the Soviet Union, the Cuban government has continued to offer free health care to the population. However, as resources have fallen, these free services have become practically worthless. For example, my maid’s brother was hospitalized for a heart condition shortly before we left Cuba in 1998. The hospital provided no sheets, towels, soap or food—these had to be brought in by relatives. An operation was scheduled, then repeatedly postponed because vital equipment had broken down. The family was told that necessary medications were unavailable; however, when they produced dollars (thanks to under-the-table payments from me), the medicine miraculously appeared.

Ironically, given this situation, health care is big business for Cuba, in the form of “health tourism.” Special clinics and hospital wings are set aside for paying foreign clients. According to a U.S. government summary, in 1996, more than 7,000 “health tourists” paid Cuba $25 million for medical services. Biotechnology is also a leading hard-currency earner for Cuba. In 1995, Cuba exported $125 million dollars worth of medical supplies.

The report goes on to point out that in 1995, Cuba’s imports totaled $2.8 billion, yet only $46 million—only 1.5 percent of overall foreign purchases—was spent on medical imports for its 11 million people. In comparison, the Dominican Republic spent $208 million on medical imports for its 7.5 million citizens in 1995.

Meanwhile, ordinary Cubans who happen to have dollars (whether from relatives abroad or black-market sources) are not permitted to purchase medicine or treatment in the clinics for foreigners and government officials. Perhaps it is feared that pent-up demand would quickly exhaust these hospitals’ supplies, causing shortages for the privileged. This is why I had to bluff my way into Cira Garcia’s pharmacy to buy medicine for my Cuban gardener.

AD: A recent report by the American Association for World Health headed by Dr. Peter G. Bourne (Jimmy Carter is its Honorary Chairman) asserts that the U.S. embargo on Cuba “has dramatically harmed the health and nutrition of large numbers of ordinary Cuban citizens [and] caused a significant rise in suffering – and even deaths – in Cuba.” In particular, the report cites the U.S. embargo on food and the de facto ban on subsidiary trade in medicines and medical supplies for “wreaking havoc” with Cuba’s primary health care system. (The full report is available online at http://usaengage.org/studies/cuba.html.)

What evidence did you see that the U.S. embargo was responsible for the kinds of inadequacies and inequities you identified in Havana?

Linderman: First of all, I must point out that my experiences in Cuba have by no means made me a supporter of the U.S. embargo. Its main function seems to be that of an all-too-convenient scapegoat for Cuban officials (and third-country observers) trying to explain away the deficiencies of a dysfunctional socialist economy.

Undoubtedly, the embargo inflicts economic costs on Cuba, and thus on its people. Shipping costs from many countries are more expensive than they would be from the U.S. Certain unique American products (including some pharmaceuticals and medical equipment) are more difficult for Cuba to acquire, although the embargo allows donations and licensed exports of such products.

According to the AAWH report, export license applications are discouraged, denied or stifled by bureaucracy. However, the U.S. government responds that since 1992, 36 out of 39 license requests from U.S. companies and their subsidiaries for sales of medical items to Cuba have been approved. The dollar amount of these sales is over $1,600,000. Furthermore, the U.S. government licensed more than $227 million in humanitarian donations of medicines and medical supplies to Cuba between 1993 and 1997.

Meanwhile, Mexico’s huge market is just as close to Cuba as that of the United States. The medicines I purchased with dollars during my stay in Cuba were from Mexico, Uruguay and Cuba itself. Along with hot dogs from Canada and canned vegetables from Spain, Havana’s hard-currency stores stocked American candy bars and breakfast cereals, along with plenty of Coca-Cola, imported through Mexico.

It seems to me that Cuba could acquire any product it wanted—if it had the money to pay. As The Economist pointed out in a special report on Cuba (April 6, 1996), “Since 1986, when it stopped making payments on its debt to Western banks and institutions, Cuba has been shut out of the international credit markets.”

The AAWH report emphasizes the drops in health and nutrition indicators occurring from 1990 to 1995. These have little to do with the embargo and everything to do with the loss of Soviet subsidies, which kept the Cuban economy artificially afloat. The report itself notes that: “After 1989, Cuba lost an annual $4-6 billion in subsidized and bartered trade. Overnight, all imports required hard currency. In a two-year span, the economy contracted by 35 percent ...”

The Cuban people are suffering today. They are denied the chance to earn hard currency at legitimate jobs. Their ration cards offer barely enough food for survival. Milk is provided only to children under seven. The elderly receive an unpalatable soy supplement. Herbal remedies are on the rise as medicines disappear. Lifting the embargo, in spite of continuing human rights violations in Cuba, may be a sensible and humanitarian step. But true progress in health care and nutrition, I fear, will not come until the creative energy of the Cuban people is unleashed within a free economy, in a free country.

AD: Thank you, Mrs. Linderman.

Patricia Linderman earned an M.A. in German literature at the University of Georgia, with additional study in Germany, and has worked as an English teacher, editor, and translator. She and her husband have been posted over the past nine years in Port of Spain, Santiago, Havana, and now Leipzig.

Be sure to read Mrs. Linderman's account of the risks of obtaining private medical care in Castro's Cuba, in Doctors for Dollars: "A decent life in Cuba required dollars. The catch was that most ways to earn them were illegal. Dr. Eduardo had begun to make discreet house calls, quietly accepting twenty dollars for his services ... He smiled conspiratorially when I slipped him the twenty."

Click here to send the editor your own comments or questions for Mrs. Linderman about medical conditions in Cuba.

Ralph D. Sawyer on Chinese Warfare: The Paradox of the Unlearned Lesson. "From any reasonable perspective China’s continuity has been cultural rather than political, its heritage throughout one of incessant conflict as different peoples, states, and popular movements fought to control its populace and resources."

Minxin Pei asks, Is China Unstable? "China... will face rising instability if the regime fails to undertake significant political reform in the next decade."

Carl Fritz on China in 1945: One Man's Experience. "My unit was an air service group, and when the war ended members of the unit were widely scattered all over China."

Thomas D. Grant on Taiwan Trouble. "Taiwan had almost all the traits of a separate state, except that it never claimed to be a separate state."

Joseph J. Borich on US-China Relations: Springtime Ice Beginning to Melt. "Since mid-June, there have been several signs that bilateral relations may be gradually improving."

Other Current Articles:

Nicholas Sarantakes on American reaction to the 1960 US-Japanese security treaty crisis, in Alliance in Doubt:
" The American media convinced many senators that Japan was on the edge of a Marxist revolution."

David Brown on policy implicataions for the US one year after the outbreak of the financial crisis in Southeast Asia:
"The Treasury Department has played too prominent a role . . . . The Secretary of State should be [more] visibly involved in defining and implementing U.S. policy."