CASTRO'S DOCTOR DIPLOMACY Virgilio Beato-Núñez, MD, Enrique Cantón, MD, Gladys Cárdenas, DO, José Carro, MD, et al The Medical Sentinel Feature Article Castro's "Doctor Diplomacy" Introduction   Cuba's health services have come under attention recently.(1,2) Since 1963, Fidel Castro has been exporting health care personnel including physicians to countries in Africa, Latin America, and Asia. It is estimated that approximately 5 percent of the Cuban physicians working for Castro's MINSAP (Cuban Public Health Service) are involved in service abroad.(3) The so-called "doctor diplomacy" may have begun in the manner of an assistance program for guerrilla movements, but it soon turned into big business for Havana. In this article, we analyze briefly the current events that led to two physicians serving in Castro's "doctor diplomacy" in Africa to desert in a maneuver that turned dangerous for them and for innocent bystanders.(4) Furthermore, we analyze the recent offer from Fidel Castro to train low-income Americans in medical sciences in order to remedy the health statistics of the United States in the context of the "doctor diplomacy" --- one of Castro's ways to influence public opinion abroad. The Breadth and Scope of "Doctor Diplomacy" The story of two Cuban physicians who were serving in Castro's elite "doctor diplomacy" service in Zimbabwe became front page material when they dangerously escaped from being kidnapped and returned to Cuba under the "long arms of the revolution."(2) The doctors who managed to escape, Drs. Leonel Cordova and Mirta Peña, were two of the thousands of physicians and health care personnel who are currently stationed in carefully crafted, thoroughly supervised and managed units in many countries of the so-called Third World. The income to Castro's purse from this "doctor diplomacy" in Zimbabwe alone is estimated at $1.2 million (U.S.) per month.(4) A very small fraction of this goes to pay the physicians themselves and their families in the island. Contrasting with the saga of the doctors serving in Zimbabwe, two weeks ago, Castro offered free medical instruction to recruit and register Americans to join his "doctor diplomacy."(5) Castro's offer was made to "low income Americans" who were invited to study medicine in Cuba for free and then return to the United States to provide treatment for the poor and underserved in what may turn into the latest twist of the "doctor diplomacy" schemes. These events seem to be temporally intertwined making it possible to look at them chronologically. Let us retrace them together from the various press releases that have appeared later. On May 26, the first signs of defection of Drs. Cordova and Peña were noted in Havana. During the weekend of June 3-4, Castro offered free medical training for low income Americans to a congressional delegation of African-American lawmakers that were touring Cuba. At that time, the communist leader was already attempting to divert the defection by kidnapping the Cuban doctors, ordering them to return to Havana via Paris.4 Later, when the logistics in Zimbabwe and South Africa became known through a note written by the defecting doctors and the press coverage, perhaps Castro attempted to divert negative public opinion on his "doctor diplomacy" by offering free medical training to Americans. Castro made the free training offer without consulting the proper authorities in his own MINSAP. He just commented to the press on this "offer that could not be refused" after Democrat Rep. Bennie Thompson told him that his Mississippi Delta congressional district has an infant mortality rate much higher than that of Cuba. According to the Associated Press, Castro stated: "It would be hard for your government to oppose such a program. It would be a trial for them. Morally, how could they refuse?"(5) We feel compelled to reject the offer made by FIdel Castro. His is an offer of malicious distraction, and a propagandistic attempt to improve on the perception of the health standards and achievement claims of his Revolution.(6) Castro has used these claims to justify all aspects of his 41 year rule by a single party and a single individual --- himself. Our conclusion is based on facts that can be described and analyzed. The first consideration in assessing the offer by Fidel Castro for free medical training is that medicine is in reality a social science that uses the methods of the natural sciences to attain four goals: to promote health, to restore health, to prevent disease, and to rehabilitate the patient.(7) The practice of medicine is therefore carried out in a social order that cannot be improvised, invented or assumed to be totally controlled or controllable --- unless, of course, one practices medicine in a totalitarian society. While it is no secret that Castro's Cuba is a totalitarian society ruled by a tyrannical leader for the past 41 years, the people of the United States and of Mississippi in particular must not be intimidated into accepting an "offer that could not be refused." Castro's offer can and must be refused on further grounds. While Castro pointed out that Cuba has an infant mortality rate of 7.3 deaths per 1000 live births,* he did not disclose that the mortality of children in Cuba in the age group from 1 to 4 years is 11.8. This latter figure is 34 percent higher than the equivalent health statistic for the United States, despite the fact that Cuba has the most comprehensively organized health service in the Americas. These official data from the Pan American Health Organization (8) and our analysis suggest that Castro has organized the MINSAP services with one goal in mind: to lower the infant mortality rate without effective consideration to other important health parameters. The importance of infant mortality is that it correlates with the overall health, education, nutrition, standard of living and well-being of the population. In Cuba's case, this is not true. Cuban health services are organized and structured so that the resources, support, and services are directed to reach the facilities that must maintain a lower infant mortality (death from the time of birth to 12.0 months). Therefore, in Castro's Cuba, life support may be artificially instituted and continued on an individual infant or a community to achieve a numerical goal in the infant mortality of a particular health sector or region. This is done without consideration to other health services that are rationed, denied, simply ignored, or blamed on the CIA, obscure reasons or the improperly called American embargo. While these excuses are made part of the propaganda, fundamental health issues such as the provision of the elements for public hygiene are not prioritized. Instead, priorities are given to the desired goals of the MINSAP, a lower infant mortality with bonuses and favors for those physicians and units that reach their goals. Therefore, infant mortality data in Cuba since the 1970s reflect the organization of the health services and the compliance of the health care personnel in terms of the promulgated and designated goals promulgated by the totalitarian State. Infant mortality in Cuba cannot be a measure of the well-being and the standard of living of the population under these circumstances. The issues on infant mortality must be developed further. The following brief analysis will demonstrate the lack of seriousness in Castro's infant mortality propaganda. Consider, for example, a health parameter linked to infant mortality, maternal mortality. The maternal mortality of Cuba in the last three years has been 26 to 33 deaths per 100,000 live births. This health statistic is not low despite the fact that Cuba has the lowest birth rate in Latin America (12.5 births per 1000 population). Cuba's maternal mortality figure is in fact 4 to 5 times greater than the equivalent parameter for the United States (8.4). Furthermore, Castro's comments to the African-American lawmakers alluded to the health status of Mississippi, a State with an infant mortality of 10.2 but a maternal mortality of 9.3.(9) It is well recognized that mortality statistics do not depend solely on medical care. Issues such as nutrition, education and communication are considered important in achieving truly significant health statistics. Therefore, unless Castro is planning to take over the economy, the schools, the agriculture, and the communications of Mississippi, how can he offer to lower this important health statistic through his "doctor diplomacy?" Physicians who take their undergraduate training in a foreign country outside the regulations of the American Association of Medical Colleges are required to apply to the Educational Commission for Foreign Medical Graduates (ECFMG). This is a regulation that applies to all individuals, foreign born or nationals, who have completed a course equivalent to that of an American medical school. The ECFMG has supervised and controlled the influx of foreign medical graduates (FMG) since its inception in the late 1950s. At this point in time, FMG's sit for the same exams offered to American medical students and graduates but the passing scores are not identical for each of these groups. The passing score of FMG's is set, among several considerations, on the number of physicians that may be desired in the U.S. for immigration purposes. Where will the graduates of this new posture of Castro's "doctor diplomacy" fit in any of these regulatory measures? It is true that Cuban FMG's have in general passed the required examinations in about 25 percent of the cases in their first attempt.(10) But even if the graduates from Castro's "doctor diplomacy" do go through the arduous passages reserved for FMG's, how are the imprints of communist social indoctrination going to fit into the training programs offered in the U.S.? Or how are the working habits, values, and merits for promotion free of political alignment or ideology going to adapt to American institutions? Some have argued that medicine under Castro in Cuba has been inappropriately contaminated with militarism, politics, specific guidelines and schemes for the management and treatment of all commonly seen illnesses, and directives on what can and cannot be written into a death certificate. Finally, medical education is known to be easily adapted to fit one or another system of indoctrination using biological or social principles.(11) Therefore, during the so-called free medical education offered by Castro, one could easily expect that students will be subjected to the systematic indoctrination that goes on in Cuban medical education under Castro. Cuban medical indoctrination has been applied to Cubans and Latin Americans enrolled in medical schools in the island since the early 1960s.(12) The indoctrination begins with the premise that the physician owes to society and the Castro regime their medical education. It continues in terms that the physician must become a communist and he or she must pledge to improve his or her skills as a communist in parallel to his or her skills as a physician. Finally, the graduate swears to be like Che Guevara.(12) Although this last goal of Castro's medical education may provide a new fashion to European designers, the fact remains that violent revolution, destruction, and death were all part and parcel of the preachings and deeds of the communist martyr of Cochabamba. While Castro told the black lawmakers that he supports their efforts to issue him credits despite the dismal status of his bankrupt economy; the bearded, legendary communist leader failed to discuss with the African-American lawmakers the current issues dealing with physicians in the island. Castro did not address anything regarding the situation of Dr. Oscar Elias Biscet, prisoner of conscience. Castro never mentioned his handling of the Colegio Médico Independiente during the destruction of Concilio Cubano in 1996.(13) Moreover, since 1999, Cuban physicians have not been able to leave Cuba with proper documentation and permits according to the MINSAP regulation Number 54.14 According to this regulation, medical doctors and dentists must serve 3 to 5 years in designated areas in the island of Cuba before they are considered for a permission to leave the island. In this manner, Cuban physicians are blatantly discriminated and made to suffer higher penalties than the rest of the professionals. Castro also failed to recall the stories of Dr. Desy Rivero(15) and Omar del Pozo Marrero,(16) both physicians who were unjustly jailed and later forcefully exiled from Cuba for reasons that perhaps Castro alone would have been able to explain to the press and the American lawmakers. And, it goes without saying that Castro failed to disclose to the lawmakers and the press those sensitive negotiations that he was carrying out with Zimbabwe's dictator-president, Robert Mugabe. The nature of those negotiations on the defection and fate of the Cuban physicians may have enlightened the lawmakers from their financial, human rights, and political perspectives. Conclusions and Summary In summary, Castro's "doctor diplomacy" involves utilizing Cuban physicians to serve in areas where the Cuban regime has entered into contractual relationships with the expressed intention of providing health care aid and establishing or nourishing diplomatic relations with the host community. The physicians serving in these units are essentially under surveillance all the time and any change in their plans not consistent with the orders given from Havana invariably lead to the involvement of police or paramilitary security forces. In the recent desertion of Dr. Cordova and Dr. Peña from southern Africa, the news media got involved in the saga about one week after its onset. This led to massive media attention and the eventual agreement between Castro and Mugabe to "let the doctors go." The terms or consequences have not been disclosed. Financially, "doctor diplomacy" is an outstanding source of income for Castro's economy since his MINSAP pays doctors and other personnel only a small fraction of the millions of dollars that are received by Cuba. Regarding the alluded health statistics for Mississippi, the offer of Castro to train for free low-income Americans must be refused because his "claims on health achievements" are based on propaganda that are not indicative of health, well-being, or adequate standards of living in Cuba. We must reject the fact that these young American students will undergo an aggressive brainwashing and indoctrinating process through which they will become Castro's pawns. They will inevitably take to Castro the much desired influx of dollars that he needs to remain in power. Finally, the specific claim of Castro that he can lower the infant mortality rate in Mississippi implies a future control by Castro of health care, finances, education, nutrition, and communications in that State. Obviously, such claims must be denounced as delusional and their malicious implications rejected. Castro's offer of free medical training to serve the poor and underserved can and must be refused. First and foremost, it must be refused because there is no need to turn Mississippi or any State or region of the United States into another Cuba. Second, there is no need for hundreds of young Americans to turn into Che Guevaras, who will then come into the United States to preach and practice death, hate, and oppression of individual and collective rights and liberties. Furthermore, there is no need to adopt the propaganda in "Castro's revolution health achievements" without recognizing their hidden liabilities: widespread alcoholism, sociopathic behavior, low birth weights, endemic giardiasis, growing incidence of hepatitis E infection, widespread venereal diseases, very high abortion rates, high maternal mortality, double to triple the deaths from unintentional injuries and accidents. Finally, there is no need to guide the wholesome medical vocations of young people in the United States from any race, creed, nationality or income bracket to become physicians in Cuba. Castro's is a society that will likely turn them into revolutionaries looking for some "Mission Impossible" scheme in order to establish an elusive, egalitarian, socialist worker's paradise that has never existed. Instead, it has forged chains on the people and a Hell on Earth wherever it has been established.   Footnote * This figure is highly open to question and does not agree with U.S. government figures as published elsewhere. For example, I suspect "live" is subject to Fidel Castro's interpretation. See Tom Carter, "Cuba was 'advanced' before Castro took over, report says." The Washington Times, March 29, 1998, p. 23. It cited an infant mortality figure of 12 per 1000 live births, according to Cuban government figures. References 1. Cuba sells snake oil to visiting congressmen. Miami Herald, June 6, 2000, p. 6B. 2. Gaither C, Marques-García S. Castro maneuvers to bar doctors' defection to U.S. Miami Herald, June 11, 2000. 3. Miranda OC. Recursos humanos en salud de Cuba. Educ. Med. Salud. 1986;20(3):375-381. 4. Gaither C. Diserción en Zimbabwe empaña la "diplomacia médica" de Castro. El Nuevo Herald, June, 12, 2000. 5. Shepard P. Castro to offer medical training. Associated Press, June 4, 2000. 6. Breo D. In socialist Cuba, primary care now reaches rural areas. American Medical News, July 25, 1977, pp. 11-13. 7. Martí-Ibañez F. To be a doctor. Miami Medicine, November 1987, pp. 27-29. 8. Health situation in the Americas. Pan American Health Organization. Basic Health Indicators 1999. PAHO/99.01, Washington, DC. 9. Personal communication with Dr. Thompson, Head of the Mississippi Health Department contacted by telephone. 10. Seywell RM, Studnick J, Bean JA, Ludke R. A performance comparison: USMG-FMG house staff physicians. Amer. Journal Public Health 1980;70(1):23-28. 11. Stetten D. The medical school curriculum: the indoctrination of the medical student. Bull. New York Acad. Med. 1973;49(4):285-288. 12. Gordon AM. Medicine in Cuba. Lancet 1983, October 29; 2 (8357):1026. 13. Amnesty International. Cuba: government crackdown on dissent. April 1996. AI Index: AMR 25/14/96. 14. El gobierno Cubano pone trabas a los viajes de médicos y dentistas. El Nuevo Herald, September 13, 1999.| 15. Cuba: doctors imprisoned. Lancet 1998;351:439-440. 16. Gordon AM. Omar del Pozo Marrero, physician prisoner of conscience. Lancet 1995. August 19; 346 (8973):509. The collaborators for this paper were: Virgilio Beato-Núñez, M.D.; Enrique Cantón, M.D.; Gladys Cárdenas, D.O.; José Carro, M.D.; Alberto Fibla, M.D.; Sergio González-Arias, M.D.; Antonio Gordon, M.D., Ph.D.; Eduardo Martínez, M.D.; Manuel Peñalver, M.D.; Juan C. Pérez-Espinosa, D.O.; E. Ricardo Puig, M.D.; Joel Silverman, D.O. Finlay Medical Society, P.O. Box 523096, Miami, FL 33152, http://www.finlay-online.com. Originally published in the Medical Sentinel 2000;5(5):163-166. Copyright ©2000 Association of American Physicians and Surgeons.