The Neglected State-builder

One of the neglected dimensions of state-building assistance in the so-called ‘arc of responsibility’ — though the benefactors would eschew the expression in favour of an unfashionable term like ‘international solidarity’ — is the growing contribution of Cuban health and literacy programs in the Pacific. These are now taking place on such a scale in the region that their neglect in the Australian media may only be explicable as the product of residual Cold War style enmities or, perhaps, as an ‘inconvenient truth’ about our closest neighbours’ unmet development needs.

Cuba provides the overwhelming majority of medical assistance in Timor-Leste, with 305 health workers on two-year missions, comprising 230 doctors, 25 nurses, and 50 health technicians. Cuba is also building capacity for the future with 600 East Timorese medical and allied students being trained on full scholarships in several Cuban universities. First proposed at a Non-Aligned Movement meeting in Kuala Lumpur in 2003, a formal cooperating agreement between Timor-Leste and Cuba was finalised in January 2007. Under the program’s ‘doctor replacement policy’, East Timorese graduates will ultimately replace the Cuban contingent within seven to eight years. Alongside the Cuban doctors and scholarships for Timorese students, a third element of the program establishes a medical faculty at the National University of Timor Lorosa’e. This separate cohort of 105 students in Timor-Leste is being trained under a new program of general integrated health instruction, first pioneered by Cuban medical teams in Venezuela. Under this program, East Timorese medical students work under the tutorship of sixty Cuban doctors, accompanying them on their daily rounds in the communities where the students live. This day-to-day practical experience is integrated with formal university training, and conducted in cooperation with the World Health Organisation to ensure standards. More than half of these Timorese students are now in their second year.*

One specific objective of the cooperation agreement in Timor-Leste was the reduction of maternal and child mortality rates, especially in rural areas. A recent program evaluation found that in the areas where Cuban doctors work child mortality is now 27.5 per 1000, a figure more than 50 per cent lower than elsewhere in the country. Maternal mortality has also steeply declined in the areas where Cuban medical teams work. The overall aim of the scholarship program is to achieve a ratio of one doctor per 1500–2000 East Timorese by 2015, when the estimated population of Timor-Leste will be 1.5 million.

Other active programs in the Pacific region include Kiribati, which hosts a Cuban health team of twenty doctors, with more to come in 2009, and the Solomon Islands, which is recruiting Cuban doctors to reduce its present doctor/patient ratio of 1:10,000, and earlier this year received the first contingent of a future cohort of forty doctors. Other cooperation agreement programs exist with Tuvalu and Nauru.

Back in Cuba, alongside the 600 Timorese medical students are 64 Pacific Islander students comprising 25 Solomon Islanders, 20 i-Kiribati, 17 ni-Vanuatu and 2 Nauruans. Planning is also advanced for a contingent of Cuban doctors in Papua New Guinea, despite strong diplomatic pressure from former Australian Foreign Minister Alexander Downer in 2007, who warned through the Australian High Commission in Port Moresby that the presence of Cuban doctors could ‘destabilise security in the Pacific’. In a rare display of defiance against the regional power, this pressure was overtly resisted by PNG Prime Minister Somare, with his health minister replying publicly that ‘really, it’s our concern whether we bring Cuban doctors’. There are also reports of Fijian interest in a health cooperation
agreement with Cuba.

In total, more than 126,000 Cubans have completed health missions in 104 countries, including large scale missions after natural disasters in Asia, such as the post-Tsunami teams in Aceh and Sri Lanka, a contingent of 1000 doctors in Pakistani Kashmir after the earthquakes in 2005, and two field hospitals after the 2006 earthquakes in Java. There are currently some 37,000 Cuban health professionals working in 70 countries, and 25,000 medical and allied students from 123 countries studying in Cuba, including 100 from the United States. Cuba is also training 21,500 medical students ‘offshore’ in their home countries, with the vast majority of these in Venezuela, being taught by 9230 Cuban doctors, and smaller programs in Guinea-Bissau and Timor-Leste. It is therefore no exaggeration to describe the Cuban programs as a global health program. The Cuban health programs are well suited for the developing world and Pacific nations, with a strong focus on preventative and community medicine and specific programs on malaria, HIV/AIDS, cataracts, and other diseases prevalent in developing countries. It is also better suited to systems with poor medical facilities, as the preventative community heath focus is less critically reliant on advanced medical technology than systems in developed countries.

Perhaps the most remarkable program, from an Australian perspective, was the Cuban-run English literacy program in New Zealand, among Maori and Pacific Islander communities. The Cuban literacy program Yo Sí Puedo (Yes I Can) runs in twenty-eight countries, in several languages, including Portuguese and Tetum language literacy curricula operated by eleven Cuban teachers in Timor-Leste. In 2003, the rector of the University Te Wananga o Aotearoa in New Zealand, Rongo Wetere, requested the assistance of Cuban literacy educators to solve entrenched illiteracy among Maori communities. A pilot project using the Yo Sí Puedo method started in June 2003 in two Maori and one Pacific Islander communities — with more than 5000 participants. Despite considerable opposition from at least one National MP, the program had 3168 people in classes as of June 2008, of whom 2092 had become literate since the program’s commencement.

These Pacific region missions are an increasing part of Cuba’s global health and literacy programs, which are distinctive in their emphasis on ‘south–south’ cooperation between developing countries, and the durable numbers of doctors and future graduates involved. So significant have these programs become that in September this year the inaugural ‘Cuba–Pacific Islands Ministerial Meeting’ was held in Havana. The stated goals of this new forum are to ‘assist small island developing states in addressing the effects of climate change, and in strengthening co-operation in health, sports and education’.

The Cuban health and literacy programs in Timor-Leste are notable, as President Ramos-Horta has often reminded reporters since, as the only international aid missions not to leave the country during the 2006 political crisis. Malmierca Diaz, the Cuban ambassador to the United Nations, stated in his address to the 2006 Security Council meeting endorsing the new International Stabilisation Force (ISF) presence that there had been too much focus on security, and too little on ‘the urgent and serious structural, economic and social problems’ afflicting developing nations like Timor-Leste. For Antonio Pubillones, a Specialist in International Cooperation from the Cuban Ministry of Foreign Relations, the ‘doctor replacement policy’ — embodied in the scholarships program — demonstrates a genuine desire to build capacity in the long term, rather than create a situation of enforced dependence on Cuba. While the health agreements clearly stand to benefit Cuba in terms of goodwill, Cuban cooperation officials are notably averse to the language of ‘state-building’, and stress that the health cooperation programs are technical agreements imposing no conditions, with wider health policy issues the sole preserve of host governments.

Despite one prominent attempt by the deceased rebel leader Alfredo Reinado to ‘redbait’ the former FRETILIN government on the issue in 2006, the Cuban health program remains as strongly supported by President Ramos-Horta and the new AMP government as it was by the former FRETILIN administration. And while there is considerable scepticism, and occasional hostility, from the US and Australian governments, they have ultimately been unable to mount substantive criticisms of Cuban health programs in the face of endemic doctor shortages in the region. Certainly, the charge the Cuba is ‘buying votes’ in the United Nations is easy to refute, as there has never been significant international support for the US blockade of Cuba and, with the sole exception of the Federated States of Micronesia (a ‘sovereign state in free association with the US’), none at all in the Asia-Pacific region.

Rather, the motivation for Cuban health programs appears to follow a more complex political and humanitarian logic: first, of internal legitimacy within the Cuban state socialist system, with its historical focus on universal health provision and internationalism as measures of good ‘socialist’ citizenship; and second, as a means of developing ‘south–south’ modes of development cooperation, and reinforcing the Non-Aligned Movement with practical development initiatives — all of which have broad implications for a ‘north– south’ balance of power which Cuba no doubt views as constructive. While it is true that the massive health program in Venezuela has reciprocal benefits for Cuba in the form of subsided oil, this ‘special program’ is an exception. In most cases, the costs of Cuban health and literacy cooperation programs are substantially borne by the Cuban government. Host countries are generally required to find accommodation for doctors, while the Cuban government pays doctors’ salaries and the scholarships for students studying in Cuba. While regional governments continue to face chronic doctor shortages and failing health systems, the number of Cuban health cooperation agreements is likely to expand throughout Melanesia and the Pacific in the near future.

* This paragraph was changed on 16/3/09. It has been corrected in line with the author’s original text. Arena Magazine apologises for the error, made during editing.

Michael Leach works at Swinburne University of Technology, and is a regular visitor to Timor-Leste.