The International Journal of Cuban Studies

(Online) ISSN 1756-347X

Integrating health and human security into foreign policy

Robert Huish and Jerry Spiegel recommend Cuba's approach of providing assistance to individuals as a practical means of combating structural violence.

Summary

Human security has been thoroughly debated as a concept and discourse that is more sensitive to the needs of disadvantaged populations; however it has been only marginally implemented in the foreign and domestic policies of the countries where its application has been most actively discussed. We feel that it is unfortunate that energy has primarily focused on theorization of the term rather than examination of empirical examples where human security is or could be put into practice. To provide a stark contrast to the much talk but little action on human security, we offer a case study of Cuba's foreign policy initiatives in primary health-care provision. Cuba sends thousands of health-care professionals to under-serviced regions of the world, and trains physicians from modest and humble backgrounds. The Cuban experience demonstrates how a policy committed to combating structural violence in the developing South leads to a practice that provides basic needs and enhances capabilities for the marginalized - at root a central concern of human security! Cuba has done a great deal to develop such policy, but this has come with internal challenges, political turmoil, and at times questionable outcomes, amid limited recognition. Nevertheless, Cuba's 48-year foreign policy of providing assistance and security at the individual level is a fitting example of human security beyond rhetoric for the twenty-first century.

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Introduction

After landing in Cuba's Sierra de Maestra in 1956, Ernesto 'Che' Guevara and eighty-eight fellow guerillas came under machine gun fire from Fulgencio Batista's troops. Guevara, the only doctor among the rebels, who had set up numerous clinics for underserved populations in one room huts, was forced "to choose between a case of bullets and a case of medicines. He couldn't carry both and decided on the bullets" (Galeano, 1985).

A decade later, with Cuba's revolutionary government now well established - and health services made universally accessible, Guevara sought to reach out elsewhere in Latin America. Again he chose the bullets, but this time with catastrophically unsuccessful results. Ironically, some fifty years after Guevara made his initial choice for advancing social change, Cuba is earning worldwide recognition and respect for its provision of health services and health training through its foreign relations with other so-called developing countries. It is, in a sense, going back for that case of medicine that Guevara left behind.

Cuba's "revolutionary purpose," as Schwab (1999) refers to it, has shifted from a politico-military paradigm to a seemingly altruistic foreign policy framework that seeks to improve the quality of life for marginalized and desperately poor individuals. While during the 1970s and 1980s Cuba had often expressed its foreign policy through military assistance to countries in Africa and Central America in the midst of anti-colonial struggles, in recent decades it has emphasized contributions in badly needed health care and education services, which is the very essence of human security (United Nations Development Programme, 2005). As of 2007, over thirty-one thousand Cuban health-care workers were providing such services in seventy-two countries.

While the integration of human security strategies into foreign policy have been repeatedly entertained, rhetorically at least, in countries such as Canada (Axworthy, 2001), an emphasis on the protection of national interests has consistently overpowered any substantive policy shifts towards an empowerment of vulnerable individuals. In considering initiatives that seek to provide security to individuals, before states, the Cuban case often remains invisible. This echoes a virtual taboo in academic and policy circles that has systematically failed to take into full account the country's remarkable achievements in the provision of health and education, despite its widespread recognition by communities in receipt of those services around the world (Spiegel, 2006).

We examine Cuba's undertakings as a basis for assessing the potential value and power of what "human security" offers. In this context, we specifically discuss how human security has been integrated into Cuban foreign policy as it focuses on the needs and capabilities of individuals in order to work towards human development goals. We especially consider Cuba's Latin American School of Medicine (ELAM as is the Spanish acronym for Escuela Latinoamericana de Medicina), a medical school that has offered over 11,500 scholarships to students from 29 different countries under the moral commitment that they will return to serve in their home communities. As we see it, Cuba's foreign policy stands out as a pragmatic example of human security through foreign policy that reflects the nation's capabilities. It is a policy catered towards combating structural violence in the developing world - and is one that high-income countries could legitimately undertake if the will and commitment was evident.

While Cuban medical diplomacy (Feinsilver, 2006) can be observed as an altruistic and ambitious foreign policy that aids the lives of tens of thousands, it arguably brings some concerns that threaten the smooth functioning of Cuban society itself. Thus, while the service provision to thousands of the world's poor shows that state policy can save lives, it has also had felt impacts at home with thousands of skilled professionals working overseas. And at the same time, these initiatives have reinforced deepening relations with allies such as oil-rich Venezuela, and earned diplomatic recognition even from once-hostile countries like Guatemala. . In discussing this process, it is our intention to initiate a dialogue on the practicality and challenge of the Cuban approach, and its role in informing broader discussions of the impacts of human security and health in foreign policy.

Conceptualizing human security

Almost half a decade past Ogata and Sen's (2003) call for "human security now", the term remains debated, abstract and loosely defined. A concept heavily based on the theoretical, our goal in discussing the Cuban case is to develop a more grounded understanding. We use the concept of human security not for convenience, but because we feel that the term is an appropriate concept for foreign policies to adopt in order to deal with the human insecurity that globalization and growing inequality has engendered (Axworthy, 2001). As it is an abstract notion too broad to universally define and too complicated to implement into national foreign policies (Burgess and Owen, 2004), we will briefly summarize our understanding of its place in Cuban foreign policy.

Human security is fundamentally about securing individuals before nation-states; real needs before imagined desires; and immediate threats before illusory dangers. It entails a balance between meeting needs and providing capabilities to individuals. It is anthropocentric by nature, and flags an individual's right to health, shelter, sustenance and liberty as essential criteria for its fulfillment. Mgbeoji (2006) argues, and Gideon's (2006) study shows, neo-liberal policies constitute a threat to human security worldwide. Health sector reforms and trade liberalization have made it more difficult for the world's poor to access safe and available health-care services. Education has become more restrictive, and affordable housing is far from guaranteed. Policies, worldwide, aimed at trade liberalization and structural adjustments have resulted in poor and working classes living worse, while the wealthiest people on the planet continue to prosper. For Harvey (2005), this consequence of globalization was never a utopia to be realized, but rather a political project intended to restore power and wealth to the elites of this planet, at the cost of safety and security for the most destitute.

For Owen, an appropriate conceptualization of human security comes directly from the UNDP's orientation that emphasizes guaranteeing basic needs and also employs threshold definitions of taking action towards threats against vulnerable individuals. He thus argues for identifying "critical and pervasive threats to the vital core of individuals" that "actually affect people" (Owen, 2004: 382). However, he ultimately opts to limit threats by their severity rather than their cause, and while allowing all possible harms to be considered, he selectively limits those threats that at any time are prioritized with the more traditionally defined 'security' label (Owen, 2004: 381). As he puts it:

"First, human security must recognize that there is no difference between deaths from floods, communicable disease, or war, as all preventable harms could potentially become threats to human security. However, people can be harmed by such a vast array of threats that complete coverage is conceptually, practically, and analytically unfeasible." (Owen, 2004: 382).

While Owen's definition lends itself well to a working theorization of human security, the idea of identifying the severity of a threat rather than the root cause of insecurity is problematic. At what point is insecurity deemed to be severe? Who makes the decision as to when action is taken against a threat rather than maintaining a comfortable tolerance?

Such an approach also requires a continual redefinition of thresholds. For example, tolerating human insecurity could be defined as life on $1 a day versus a relative threshold of security on $2 a day. Or say the difference between infant mortality of 200 deaths per 1,000 live births versus 100 deaths per 1,000 live births. As child mortality in Haiti is half that to Sierra Leone, is it justifiable to tolerate a lesser commitment to human security in Haiti? As long as unbridled inequity to resources exists, and current trade and aid policies reinforce that division, human security policy will be in a continual state of redefining what level of misery is acceptable, what requires attention, and what is beyond hope.

Rather than responding to intolerable thresholds, Cuban medical internationalism works to overcome structural violence, which is a root cause of human insecurity. Best understood as social, economic, cultural, and gender structures that prohibit individuals from meeting their full potential (Galtung and Hoivik, 1971), structural violence ultimately prohibits human security. Willet (2001) sees the unequal distribution of wealth as a contributor to structural violence that has ultimately undermined human security. As Farmer (2004) argues, globalization has created structures that not only prohibit individuals from reaching their full potential, but often force the poorest people on the planet to a condition of continuously choosing against accessing health care due to the cost, inconvenience, and absence of services. Building a dam that displaces peasants who then lose their livelihoods, and subsequently dwell in dangerous slums in order to live on a couple of dollars a day, is, to Farmer (2005), structural violence. The dam does not physically attack the peasants, but it does limit their ability to achieve health and well being. Human security has a place in preventing root causes that lead to death by hunger, or living in dangerous environments, by going beyond the medical conditions to address the pathologies of poverty and risk that make such health calamities all too common for the world's poorest populations. Musah (2002) makes this sort of connection in Africa between the increase in structural violence and the decrease in human security. Overcoming structural violence, as Farmer suggests, requires broader social, economic, but most importantly, political support to address the health of its victims. Yet, at the same time, it must work to provide health and well-being for victims of structural violence.

The Cuban case

While myriad empirical examples of human insecurity exist, such as Schmeidl's discussion of the status of Afghan refugees, few definable examples of human security as a state that can be "constructed" have been brought into the dialogue (Schmeidl, 2002). Cuban medical internationalism is nevertheless precisely an example of promoting human security that is aimed explicitly at overcoming structural violence through community-based health provision, individual empowerment and long-term capacity building (Huish and Kirk, 2007). These strategies are important case studies to help conceptualize working examples of human security policy. We see them as an appropriate mix to form the building blocks of protecting individuals from structural violence, and yet we acknowledge that these examples are not without their consequences.

Health-care service providers, according to the WHO, personify fundamental humanist values, "they heal and care for people, ease pain and suffering, prevent disease and mitigate risk - the human link that connects knowledge to health action" (The World Health Organization, 2006). The WHO argues that empowering human resources for health can only lead to advancements in the equity of knowledge and care for desperately under-serviced regions. As Beaglehole and Dal Poz (2003) argue, strengthened public health services can more comprehensively ensure equity in health interventions and access to resources, where, traditionally, they have favoured elites. This does not prevent broad macro-economic structural adjustments that can be the root cause of structural violence, but a strong public health-care workforce gives marginalized populations greater access to necessary medical care. The 2006 WHO report concludes that infant, child and maternal mortality all drastically decrease with a higher concentration and accessibility of trained health-care professionals. As well, greater access to medications and vaccines vividly improve with heightened accessibility to health-care professionals (The World Health Organization, 2006).

Cuba has understood these relationships and has taken action to increase its number of health-care professionals, mostly doctors and nurses, to work in under-serviced regions around the world. All too often, the demand for their services is overwhelming. In East Timor, for example, violent clashes in August 1999 displaced 75 percent of the population and left only 35 physicians in a country of about one million people. That made for a doctor to patient ratio of one physician for every 28,571 people. The number later increased to 79 physicians, according to 2004 WHO data, and Cuba sent an additional 182 physicians and technicians to the country to offer support. Health workers in the country continue to go up against difficult conditions, and in order to further increase capacity, Cuba offered 800 ELAM scholarships for East Timor youth. If all scholarships were filled, and if all graduates returned to the country, the doctor to patient ratio would be one physician for every 1,250 people.

Human security endeavours have been a long-standing part of Cuban foreign policy, even in the earliest stages of the 1959 revolution. While Cuba has participated in various military security efforts in Africa and Latin America, most activities have focused around health and education at the community level. In 1961, a Cuban medical brigade accompanied a military expedition to Algeria to aid ongoing revolutionary struggles. As Gleijeses (1996) notes, the handful of Cuban doctors that went to Algeria provided the only medical attention available to rebel fighters on the ground. This was a profound offering of human resources from 1961-1965, at a time when Cuba itself experienced numerous poverty-related health problems and was recovering from the loss of 3,000 doctors who fled after the revolution.

The other, more famous, example of Cuban medical internationalism involved the conflict in Angola where the Cuban medical brigade constituted a sizeable percent of the larger military core of 350,000 people. The Cuban medical personnel worked on the ground to treat their own ill and wounded, but they also tended to Angolan military and civilian casualties free of charge (Cohen, 1994) In 1986, Angola had only 230 native-born doctors, of a total of 880 practicing physicians. The doctor to patient ratio was estimated at 1 doctor for every 10,250 people, despite the presence of foreign doctors, of whom 323 (41%) were Cuban.

Cuba's efforts demonstrate a commitment to establishing services for the immediate and long-term needs of the populations it serves. In Algeria and Angola, Cuban staff worked to train locals to be medical technicians, doctor's assistants and nurse's aides (Gleijeses, 1997). In Angola, Cuba established sixteen field hospitals that were staffed with locals (Cohen, 1994). In 1970, following a massive earthquake that devastated parts of Peru, Cuban field hospitals acted as the only point of entry into primary care for hundreds of rural Peruvians. As for the 1972 earthquake that leveled Managua, Nicaragua, the Cuban medical brigades remained well after the initial clean-up and repair stages of this disaster. In fact, medical brigades have returned to Nicaragua every year since the mid-1970s. Their efforts have been essential in delivering vaccinations and attending to childbirth for marginalized populations that would not otherwise have received medical care.

Cuba's commitment to long-term primary care ensures that health-care professionals not only go to remote regions, but stay there as well. Not only have Cuban medical brigades remained in countries during times of violence or conflict; they have also focused on building sustainable health-care networks by training locals as health professionals. For human security to succeed in marginalized areas, health professionals cannot be in a continual state of transition, as recycling personnel does not allow for the establishment of important long-term relationships that build trust. According to our interviews with representatives from MINREX (the Cuban ministry for foreign affairs), in March 2007, Cuban internationalism succeeds because of an ethos that sees sick people as patients, not clients, and treatment being about the patient rather than the disease. The goal is, according to MINREX, not just beating disease, but to build health in the community, which includes having doctors in the community and encouraging medical students from those communities to return home to establish long-term care. Cuban physicians working abroad often apprentice medical students from the communities in which they serve. Training students in their communities is similar to the time a resident spends training in an emergency ward. By learning through experience, the physician is better prepared with the confidence for real life conditions.

This approach of training students in the clinic, called morfofisiologia, is at the heart of the Cuban approach. In fact, the 42,000 students receiving medical training from Cuban physicians abroad spend 70 percent of their instructional time in the clinic and only 30 percent in the classroom. MINREX claims that developing a skill set based on practice, rather than perception, not only gives students clinical experience, but it gives them confidence that they can make an impact in their own communities.

Certainly, while Cuba's human security driven foreign policy has its share of benefits for the recipient communities, and for strengthening South-South solidarity, it is not without its challenges. Despite these gains abroad some discontent has developed at home. Cubans have long enjoyed the best doctor to patient ratio anywhere in the world. However, with 31,000 health personnel working overseas, the Ministry of Health has had to cope with a reconfiguration of 139 to 179 patients per doctor (The Economist, 2007; Feinsilver, 2006). Cuba is thus experiencing a shift in traditional domestic service provision. With more doctors working abroad, patients cannot as easily call upon primary care services through the neighbourhood consultorios. Cubans still have access to family physicians, but more and more services are being allocated through the larger, and slightly more centralized polyclinicos, which are facilities that handle a variety of health concerns such as treatment, diagnostics and testing.

As Feinsilver (2006) points out, some health authorities in recipient countries take exception with Cuban doctors fearing that they will encroach on their patient base and their clientele. Physicians in Venezuela have for example grumbled at the presence of 19,000 Cuban health-care workers in their country, claiming that it impacts their financial well being, despite the fact that the Cubans are treating patients and training doctors in some of the most indigent communities in that country; the very places that these complaining physicians had previously ignored.

Another policy challenge involves the compensation of Cuban physicians working abroad. Any physician who chooses to work overseas is paid a regular salary in Cuban pesos, and they also receive a bonus in convertible currency. Often the salary and the bonus are received by the physician's family in Cuba. In the field, the host country is responsible for covering the costs, not exceeding $200 per month, of the physician's food, accommodation and other necessities. For physicians who remain in Cuba, these perks are not available, and there is concern over the inequity in compensation between doctors in foreign and domestic service.

With these challenges in mind, the problem-based medical education and community-centred care Cuba offers to combat structural violence seem to be exactly what the WHO is calling for through the establishment of equitable primary care (The World Health Organization, 2006). And while shortages of health personnel have been acknowledged to be staggering on a global level (ibid.), the Cuban approach has emerged as being quite unique in overcoming the disparity, if only by a little at a time, and with the admitted challenges at home. For this reason, Cuba's ELAM is an extraordinary example of this policy being carried out on a scale never-before seen.

ELAM: the Latin American Medical School

Among all of the long-standing international medical campaigns, it was pursuant to the response to Hurricane Mitch in 1998 that MINSAP (the Cuban ministry of health) admitted that the need for health care in the developing South was well beyond the capacity of existing Cuban medical brigades. Hurricane Mitch claimed over 30,000 lives in Honduras, Nicaragua and Guatemala, and displaced over a million persons. This immense devastation and tragic loss of life occurred, from MINSAP's perspective, because of a desperately hollow investment in appropriate infrastructure and human resources; something that internal and external neo-liberal reforms demanded during the 1990s (Muntaner et al., 2006; Horton, 2003; Ugalde and Homedes, 2005; Cardelle, 2003).

If Cuba could not send all the required health-care professionals to the affected regions, they could help to build the capacity of locals to become health leaders in their communities. To a large extent they had already been pursuing such a goal in contributing to the establishment of small medical schools in several countries, but these efforts were localized, depended upon local government cooperation, and involved small numbers of Cuban professors and medical staff. Following Hurricane Mitch, however, Cuba decided to undertake a new initiative after seeing the enormous devastation in Central America. The region suffered from a noticeable lack of human-resource and infrastructure capacity, which had been reduced thanks to a decade of neo-liberal structural adjustments. MINSAP converted a naval academy into a fully-functioning medical school in a span of six months. They proposed to accept around 1,500 students per year from the affected regions in Central America and the Caribbean. The goal, as Fidel Castro (2005) put it, was to train students from the region to replace Cuban doctors. The students would be representative of the communities in which they would serve. Women would constitute a large part of the student body, indigenous groups would be well represented, and students would come from modest and humble backgrounds. Specifically, the school set out to recruit students who were between 18-25 years of age; had high school or some university training; had no criminal record; could display physical and mental fitness; and could demonstrate a sense of ethics of serving under-serviced areas (MEDICC, 2007; ELAM Web, 2007).

Quickly, ELAM's geographic pool grew from the region affected by Mitch to include students from 29 different countries in the Americas and Africa. Despite initial challenges like dated course material, and other various infrastructural shortcomings, the school admitted over 1,400 students in 1999. Since opening the school, Havana has offered medical training to the poor of the South on a scale never before seen.

In 2005, the first class of 1,610 students graduated, this included the majority of students from the initial enrollment along with other students who fast-tracked through the program having already completed some medical training in their home countries. The average age was 26, women constituted 45.9 percent of the class and thirty-three different indigenous cultures could be identified. 71.9 percent of the graduates identified as being from rural, or economically marginalized, families. ELAM accredited 74.7 percent of the class (1,143 students) as having "un alto rendimiento académico," meaning that two thirds of the class performed well above passing standards, and 12 percent of the class received the Título de Oro, Cuba's highest award for excellence in medical education for those who retain an 84.7 percent average from inception to graduation. Unlike most medical schools, according to two ELAM students from the United States, ELAM is not set on creating bell curves. "We could all pass, we could all fail. We're not compared to each other here," said a student from Oakland California.

1,412 graduates left the school in 2006 and another 1,561 in 2007. With over 4,000 graduates to date, ELAM is playing an important role in building human resources for health for the developing South as well as in the North. In 2001, the school opened its doors to 90 students from the United States. The first graduating class provides a fitting representation of students by gender, age, and race. The curriculum, the training, and most importantly, the ethics of practicing medicine in the community is at ELAM's core, and it is hoped that this innovative training program will see graduates make impacts in their home communities (ELAM Web, 2007; Carrizo Estévez, 2007. Like most Cuban innovations in community-based primary care, there is a tremendous amount of trust in human desire, capability and altruism.

ELAM does well to foster the appropriate clinical skills and ethics of service for its graduates to meet the needs of their communities. However, because of the overwhelming structural challenges of lacking basic infrastructure within their home countries, many will not have the available resources in their communities that would facilitate the adoption of effective disease prevention and health promotion routines. Doctors returning to areas that lack infrastructural support, or who are not in direct contact with Cuban medical brigades, will likely encounter staggering challenges in applying their skills for the needs of communities. Basic infrastructure, lacking information networks and poor community-oriented health initiative are all likely challenges that face ELAM graduates. Trained human resources, while necessary and critical, may still not alone be sufficient to achieve the desired impact.

Nevertheless, ELAM has demonstrated that an alternative trend to medical education in the global South is possible, and that human resources for health can be bolstered through innovative foreign policy aimed at tackling structural violence. ELAM doctors are the empirical examples of this. They are the living reality that of policies that build a workforce dedicated to human security provision.

In Ecuador, the ELAM graduates themselves have spoken and to say that the Cuban approach should not be changed to adhere to the reality of a hollow public health-care system, but that Ecuador should change its domestic health-care policies to adhere to the ELAM experience. In May 2007, Ecuadorian alumni of Cuban institutions created the Front of Multidisciplinary Professional Graduates in Cuba, whose goal is to lobby the Ecuadorian government to find ways to embrace their skills within the public sector. This group consists of a select group of ELAM graduates, now spanning three years (2005-2007) labelled the Internationalist Federation of Health (FIS), which seeks state support in implementing programs to administer 'socialist and humanist medicine' alongside primary care. Their goal is to help create, on a broad scale, the necessary political and social support to build widespread programs of disease prevention and health promotion. These strategies were made successful in Cuba by intersectoral collaborations governed by strong political leadership, and the idea is that it can be made possible in Ecuador with similar support.

The FIS is lobbying for widespread human security provision on a scale to overcome structural violence. This includes ensuring popular education, sanitation, food security, literacy, and health-care access. Their manifesto reads that they will return to Ecuador as doctors, but also as leaders in popular health provision. They are asking President Correa's government to embrace their confidence. The ELAM graduates have realized the challenges that await them. Instead of giving in, instead of finding lucrative places in the private sector, they have organized, vocalized and encouraged the government to radicalize the means of health-care access. Their popular commitment to ELAM's goals and values demonstrate this surprising success of a will to change the system in order to overcome structural violence.

ELAM is the latest, and certainly the largest step in Cuban medical internationalism. What may seem to be a radical program is really only a progression in a way of thought, one that is dedicated to delivering accessible health-care services to marginalized communities. It remains to be seen if ELAM will have the ability to alter the health-care landscape of the developing South. Many of the graduates will return to their countries to cope with anaemic public health sectors, hostile private physicians associations, and a generally lacking supply of human and material resources to aid them in serving the poor. Already a great deal of pressure exists for medical graduates from the South to migrate to cities, to the north or to private sectors (Eckhert, 2002; Hallock, Seeling and Norcini, 2003; Boulet et al., 2006). ELAM graduates will face the same pressures as their countries struggle to find appropriate means of supporting their profession. Indeed it will be a test of the strength of ELAM's moral commitment.

Conclusion

That case of medicine Che Guevara left on the hills of the Sierra Maestra seems to have blossomed into a core component of Cuban foreign policy. Cuba's extensive commitment to accessibility of health care and long-term human resource capacity building is a working example of human security. It is, as we see it, an important process to consider the place of human security in foreign policy. Considering that human security has traditionally been thought of too abstract, Cuba shows us that by committing human and material resources to fighting structural violence, it is possible to embrace it as part of foreign affairs policy.

To effectively bring the Cuban experience into the human security dialogue we agree with Roberts (2006) that the focus of the future of human security discussions should be less about contrasting the broad and narrow definitions against each other and to actually look at what defines human insecurity. Moreover, policy dialogues need to be move past the rhetorical definitions of human security, and address how policies of trade-liberalization and structural adjustments have actively contributed to human insecurity. We argue that it is important to identify the human insecurities and then explore solutions through the failures and successes of empirical examples, such as Cuban medical internationalism and ELAM. Discovering the needs of communities, envisioning solutions and studying empirical attempts will build frank discussion that will help to understand our capabilities from what has been done in the past. Without such an approach, human security will likely remain a dubious and abstract term that will consume energies in debates of semantics. It is time to define and explore human security through empirical examples of overcoming structural violence, otherwise academic and policy forums will continue to debate the meaning of the term until the end of time; something that the marginalized of this world simply can't wait for.

Robert Huish is a postgraduate researcher at the University of Montreal, Canada.
Email rlhuish@sfu.ca

Jerry Spiegel is Director of Global Health at the Liu Institute for Global Issues, University of British Columbia, Canada. Email jerry.spiegel@ubc.ca

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