Cuban medical diplomacy (hereafter CMD) is defined as the Cuban collaboration with other countries in the health sector to simultaneously produce health benefits and improve diplomatic relations (Feinsilver, 2010). Since 1963, the year of the first medical mission in Algeria, the Cuban government has engaged in countless operations entailing the export of medical personnel abroad to fulfil other countries’ lacks. The importance of medical internationalism in Cuban foreign policy is well established in academia (Feinsilver, 2010; Benzi & Lo Brutto, 2014; Calmettes, 2013) as well as its relevance in the broader context of internationalism shaping Cuba’s foreign policy (Benzi & Zapata, 2017).
However, a tension can be outlined in the motivations leading Cuba to engage in such practice. From one standpoint, CMD is a purely ideological engagement of the island in South-South cooperation (hereafter SSC) (Xalma, 2008; Ojeda Medina, 2013): the importance of Cuba in the construction of the Global South as an operative and militant paradigm is well-known by academics (Grovogui, 2011; Benzi & Lo Brutto, 2014). From a different point of view, Cuba’s willingness to export health professionals in exchange for other benefits can be seen as a realist-driven realpolitik approach to foreign policy. In an international environment that is typically hostile — i.e., the U.S. embargo — Cuba uses medical professionals as a bargaining chip to gain power. Scholars, in fact, highlight the pragmatism underlying this practice and argue that it is motivated primarily by power concerns rather than ideological internationalism (Feinsilver, 2010; Benzi & Zapata, 2017).
This tension is particularly relevant for this research: medical diplomacy from Cuba to Venezuela will be analysed through the lens of the dualism between realism and SSC. The aim of this piece is to highlight the tension by outlining the evidence fostering both arguments, and ultimately to provide some final observations. The first two paragraphs will explain what CMD is and why it is caught in an ontological tension. The third will highlight the elements claiming CMD to be the outcome of ideological SSC. The fourth paragraph will analyse the factors asserting that it is primarily fostered by realpolitik objectives.
Cuban medical internationalism towards Venezuela is rooted in the longstanding engagement of the island in practices of solidaristic exchange (Benzi & Zapata, 2017). The most reliable studies in the field indicate that by 1986 more than 250.000 Cuban medical professionals had been deployed in Africa since the first mission to Algeria in 1963 (Dominguez, 1989). After the fall of the USSR and the consequent economic crisis that Cuba experienced, the focus of medical internationalism shifted toward Latin America and the Caribbean (2017). As the same authors argue, this mirrors Cuba’s need to revisit the role of medical diplomacy in its political and economic strategies (Benzi & Zapata, 2017). The renewed engagement in the area resulted in strong cooperation with Venezuela, especially after Hugo Chavez’s election. By 2008, more than 30.000 Cuban health professionals were operating in Venezuela (Feinsilver, 2008).
During the 1990s, Cuba found itself politically isolated and economically threatened. The fall of the socialist block and the consequent strengthening of the embargo strongly hit the island, leading to a period of crisis. In this context, Cuba-Venezuela relations started to flourish (Calmettes, 2013). When Chavez won the 1998 elections, the relations between the two countries started to grow, fostered by the ideological affinity of the two governments. After a troubled period of stabilisation of the newly elected Bolivarian government, the interaction between the two Latin American countries intensified. Agreements entailing the action of Cuban officials in Venezuela in the fields of health and education were signed in 2000 under the name of “Integrated cooperation agreements”. In 2003, the first contingent of Cuban cooperators started its work in Venezuela: Cuba began to contribute to the social programmes of the Venezuelan government, named Misiones, aimed at improving the living conditions of the lower classes (Calmettes, 2013). The involvement of Cuban health professionals in the Venezuelan social program Misión barrio adentro was, and still is, crucial, with approximately 30.000 health professionals engaged in 2008 (Feinsilver, 2008). Their contribution is both in the form of direct medical assistance and education and training of local medical personnel.
In return for the provision of such services, Cuba obtains a considerable amount of Venezuelan oil, whose relevance is such as to leading some scholars to hypothesise a potential situation of energetic dependency pattern (Mesa-Lago, 2007; Vidal, 2014). Cuban engagement in the exchange of doctors for oil is better understood considering that the price of Venezuelan oil vis-à-vis medical services is negotiated bilaterally and periodically, which allows Cuba to obtain a lower price than the market one (Benzi & Lo Brutto, 2014). Similarly, Venezuelan engagement can be explained by the country’s necessity to implement social programs to benefit the lower classes, which could hardly be realised with endogenous resources in the short term (Calmettes, 2013). Some scholars have coined the term Venezuelan oil diplomacy as a counterpart of CMD (Briceño-Ruiz, 2017).
Ideological South-South cooperation or realist realpolitik?
The ideological component that underpins CMD has often been stressed (Benzi & Zapata, 2017). This is no surprise, and it is in line with the position adopted by Cuba in the international scenario. The statement of Fidel Castro “…being internationalist means repay our debt with humanity…” (Fidel Castro in Oramas, 2012) well describes Cuban international policy after the 1959 revolution and restates the adhesion of Cuba to the principles of proletarian internationalism (Ojeda Medina, 2013). Throughout the 20th century, Cuba has been on the frontline to build a coherent movement of third-world countries and is one of the main proponents of the concept of the Global South as opposed to the Global North in a centre/periphery scheme (Grovogui, 2011; Ojeda Medina, 2019). Moreover, its government has often demanded the emancipation of the peoples of the third world with an anti-colonial and anti-imperialistic aim (Ojeda Medina, 2019).
Traditionally, Cuban engagement in medical internationalism has been seen as a manifestation of ideological engagement. However, lately, scholars have shifted their attention to the deeper motivations that underpin this practice, and some have noticed a progressive shift toward the commodification of medical internationalism (Benzi & Zapata, 2017). Adopting a realist approach, some of the aspects of this phenomenon can be explained as instances of realpolitik. The next sections will proceed as follows: Firstly, the elements that spur the conception of CMD as an example of ideological SSC are outlined. Secondly, the factors that frame CMD as moved by objectives of realpolitik are presented.
Ideological South-South cooperation
South-South cooperation can be defined as a set of practices pursuing development through a solidaristic approach among those states that are considered to be disadvantaged in the world system — i. e., the Global South (Gray & Gills, 2016; Ojeda Medina, 2019; Grovogui, 2011). Rather than being limited to mere trade relations between countries of the Global South, SSC promotes several values entailing fair trade, bilateral relations, respect for sovereignty, bilateralism, and cooperative advantage (Ojeda Medina, 2019). This paper refers to ideological SSC to describe those attitudes in international relations that can be explained by an ideological engagement of states in practices of cooperation with other countries. SSC is rooted in the Bandung conference (1955) and the consequent development of the non-aligned countries movement as opposed to the North-South approach to international relations (Gray & Gills, 2016).
Some scholars challenge the idea of SSC as univocally opposed to the dominant structures of the world system. They ask whether countries of the Global South are genuinely interested in changing the system or rather gaining more power in the existing one (Vanaik, 2013). Although SSC is not a monolithic concept and entails several different practices, the ideological component is however particularly relevant. Indeed, SSC encompasses the idea of the countries of the Global South pursuing development collectively, in observance of alternative rules that constitute a pattern of development that stands outside the realm of North-South cooperation. The end of the Cold War led to the resurgence of the Global South as an important actor in world politics, and of SSC as a development paradigm (Bergamaschi & B. Tickner, 2017). It allowed countries of the Global South to retake the process started in Bandung and build a model of cooperation that suited their necessities (Tavis & Silva, 2008).
The ideological commitment of CMD towards Venezuela to SSC can be deduced by two main elements: the conditions under which it was established and the modalities in which it is implemented.
Both Calmettes (2013) and Benzi & Lo Brutto (2014), retracing the history of Cuba-Venezuela cooperation — the former from a Venezuelan and the latter from a Cuban perspective — stress the importance of the ideological affinity of the two governments. Thus, drawing on their account of the development of CMD towards Venezuela, the election of Chavez and the change of the leading ideology of the Venezuelan government can be seen as the turning point of Cuba-Venezuela health cooperation, confirming the solid tie between Cuban medical internationalism towards Venezuela and the ideological component of SSC. As a corollary of this assumption, a causal correlation between the fact that no program of cooperation was put in place before Hugo Chavez’s election and the ideological discordance between Venezuelan former governments and Castro’s can be hypothesised. This suggests that CMD towards Venezuela could be primarily moved by ideological concerns, as the fact that no agreement was put in place before Chavez’s election would be hardly explainable without considering the framework of ideological SSC (Calmettes, 2013). Thus, ideological motivations can be identified in the fact that this phenomenon stemmed from the ideological affinity of the governments.
The second set of elements leading CMD towards Venezuela to be understood as a form of SSC moved by ideological motivations lies in the modalities in which it is implemented — i. e., the practical activities that Cuban health professionals perform in Venezuela, most of which appear to have a strong ideological component. As confirmed by both Cuban (Tortoló et al., 2017) and international (Benzi & Lo Brutto, 2014; Ojeda Medina, 2013) academics, the intervention of Cuban health professionals in the merit of the misión barrio adentro assumes several forms including the transfer of knowledge and technology (Benzi & Lo Brutto, 2014; Ojeda Medina, 2013; Tortoló et al., 2017). Besides the important commitment of Cuban professionals to provide direct medical assistance to those in need, the non-secondary activities of technology transfer and education of local medical professionals must be considered: the high level of technology achieved by Cuba in the medical sector allows the island to be able to couple the direct action of professionals with the direct transfer of technology toward Venezuela (Ojeda Medina, 2013). Furthermore, due to the high investments of the Cuban government in the health sector, several programmes of education for local health professionals have been put in place within misión barrio adentro and scholarships are offered to Venezuelan students to study medicine in Cuba (Calmettes, 2013). Ideological commitment can thus be found in the transfer of technology and the stigma on education: typically, in a profit-seeking logic a country that holds either a technological or educational advantage would not give it away if not strictly necessary (McCloskey, 2007). This is not the case, since Venezuela was in desperate need of health professionals when the agreements with Cuba were signed, and Cuba did not use its superiority in the medical field to generate technological dependence but rather engaged in widespread technological and educational transfers (Calmettes, 2013).
The above observations suggest that CMD towards Venezuela is ascribable to the broader picture of ideological SSC and could even be portrayed as a prominent example of it. However, the situation is more complicated. Some scholars have questioned CMD as a purely ideological commitment and have hypothesised a shift of CMD towards a tool of realist-driven realpolitik.
Classical realist narrative in IR identifies the struggle for power as the main driver of state action. Realists describe the international system as: “a brutal arena where states look for opportunities to take advantage of each other” (Mersheimer, 1994-1995, p. 134). The balance of power is a key concept of realism: great powers by asserting their mightiness build the foundation of security (Lebow, 2007). At first glance, CMD towards Venezuela seems to have little pertinence in this realm: as shown above, ideology is a key component of CMD and realism does not consider ideology as a factor that mobilises state action. In this context, the term realpolitik is closely related to realism as it is used to describe the practical application of realist principles to political practice (Bew, 2016). Benzi and Zapata (2017) have argued that CMD towards Venezuela has been progressively shifting towards commodification due to the use of medical professionals as a commodity or, as mentioned in the introduction, a bargaining chip sold in exchange for other commodities — Oil. Another relevant consideration relates to the inclusion of such a project in the Alianza Bolivariana para Nuestras Americas (ALBA), which leads to hypothesising the use of CMD to strengthen the geopolitical position of the island (Garcia Aponte, 2019). Commonalities between Venezuelan foreign policy and CMD towards Venezuela can be identified in elements such as the involvement in the ALBA — the alternative proposal for a multipolar order to challenge the global hegemony through SSC (Briceño-Ruiz, 2017).
These elements might constitute the basis for an understanding of CMD towards Venezuela as animated by realist-driven realpolitik. The use of CDM as a key contribution to fostering an alternative world order — in the framework of the ALBA — would respond to the need for Cuba to expand its influence, ultimately pursuing objectives of foreign policy. Furthermore, Feinsilver (2010), Benzi and Zapata (2017) observe that this practice is driven by the necessity for Cuba to find suitable partners pursuing survival in the post-Cold War hostile environment. Structural realism can thus be a useful analytical tool to observe CMD. In fact, it shifts the emphasis towards the structural changes of the world system that lead states to act in a certain way and, therefore, focuses on external constraints shaping statal action. The shift from the Cold War scenario to the post-1989 was indeed a crucial change for Cuba, which was left with no powerful allies. The fall of the USSR left Cuba deprotected and unable to defend itself, both politically and economically (Benzi & Lo Brutto, 2014). Structural realism also focuses on the imperative of survival as the most important concern for states (Mearsheimer, 2007). Structural constraints in the world system led Cuba to adopt what Benzi and Zapata (2017) call a commodified type of medical internationalism. Hence, Cuba sought economic benefits and political alliances somewhere else. The imperative of survival might indeed explain some of the features of CMD in Venezuela, such as its importance in the framework of the ALBA to promote an alternative hegemony and the fact that Cuba obtains a massive amount of oil which is crucial for its survival. Therefore, the instrumental use of CMD as a means of foreign policy spurs the conception of CMD as driven by objectives of realpolitik.
As briefly highlighted in this article, CMD towards Venezuela is a controversial theme. The topic has been approached from several standpoints and coming to straightforward answers to whether CMD is moved by ideological commitment or by realpolitik objectives is quite hard. However, from the analysis of the literature some observations, rather than conclusions, can be drawn. In the first place, the ideological engagement towards SSC underlying this phenomenon appears hardly deniable. As shown in this analysis, some of the features of CMD towards Venezuela can hardly be explained otherwise. However, elements of realism-driven realpolitik underpinning the Cuban effort have been pointed out. The progressive commodification of Cuban medical internationalism and its involvement in the regional project of ALBA, are explainable as acts motivated by a pragmatic approach, rather than ideologic, of the Cuban government.
Further clarification can be achieved by looking at structural realism and the imperative of survival. CMD towards Venezuela can plausibly be considered a response to structural constraints that threatened Cuba’s existence aimed at survival rather than at gaining power per se. Nevertheless, the ideological component cannot be neglected: CMD towards Venezuela is better explained as a response to external constraints within the boundaries of the ideological commitment to SSC. If the ideological component is to be ignored, in fact, some of the features of this phenomenon, such as technology transfer and engagement in education, are hardly explainable. Several elements overlap within the dualism between ideological SSC and realpolitik and can be explained differently in both theoretical frameworks. This is the case of the participation in the ALBA, which can be considered as both an ideological commitment and a move to gain power in the region. The situation is far from being clear and calls for further analysis. Identifying the motivations that underpin state action is never an easy task, and further research including perhaps a far-reaching component of discourse analysis can be helpful to better clarify the matter.
Benzi, D., & Lo Brutto, G. (2014). ¿Más allá de la cooperación Sur-Sur? Contexto, luces y sombras de la alianza Cuba-Venezuela. “De la diversidad a la consonancia: la CSS en América Latina”.
Benzi, D., & Zapata, X. (2017). Good-Bye Che: Scope, Identity, and change in Cuba's South-South cooperation. In I. Bergamaschi, P. Moore, & A. B. Tickner, South-South Cooperation Beyond the Myths: Rising Donors, New Aid Practice? (pp. 79-106). London: Palgrave McMillian.
Bergamaschi, I., & B.Tickner, A. (2017). Introduction. In I. Bergamasci, P. Moore, & A. B. Tickner, South-South Cooperation Beyond the Myths: Rising Donors, New Aid Practices? (pp. 1-29). London: Palgrave Macmillan.
Bew, J. (2016). Realpolitik: A History. New York: Oxford University Press.
Briceño-Ruiz, J. (2017). Venezuela and South-South Cooperation: Solidarity or Realpolitik? In I. Bergamaschi, P. Moore, & A. B. Tickner, South-South Cooperation Beyond the Myth: Rising Donors, New Aid Practices? (pp. 173-197). London: Palgrave Macmillan.
Calmettes, X. (2013). Continuités et ruptures d’une relation preivilégiée. In O. Folz, N. Fouurtanè, & M. Giraud, Le Venezuela d’Hugo Chavez; bilan de quatorze ans de pouvoir (pp. 307-323). Nancy: Editions universitaires de Lorraine.
Dominguez, J. (1989). To make a world safe for revolution. Cuba's foreign policy. Cambridge: Harvard University Press.
Erlich, F. D. (2010). Los cubanos en misiones de salud en Venezuela. Referencias contrapuestas y polarización discursiva. ALED, 93-110.
Feinsilver, J. (2006). La diplomacia medica cubana; Cuando la izquierda lo hizo bien. Foreign Affairs.
Feinsilver, J. (2008). Médicos por petróleo; La diplomacia médica cubana recibe una pequeña ayuda de sus amigos. Nueva Sociedad, 107-122.
Feinsilver, J. (2010). Fifty Years of Cuba's Medical Diplomacy; From Idealism to Pragmatism. Cuban Studies, 85-104.
Garcia Aponte, M. (2019). La cooperacion Sur-Sur en el ALBA-TCP. In T. Ojeda Medina, & E. Echart Munoz, La cooperacion sur-sur en america latina y el caribe: Balance de una decada (2008-2018) (pp. 173-189). Buenos Aires: CLACSO.
Gray, K., & Gills, B. K. (2016). South-South cooperation and the rise of the Global South. Third world Quarterly, 557-572.
Grovogui, S. (2011). A Revolution Nonetheless: The Global South in International Relations. The Global South, 175-190.
Gürcan, E. C. (2019). Multipolarization, South–South Cooperation, and the Rise of Post-Hegemonic Governance. London: Routledge.
Katz, C. (2008). El rediseno de America Latina; ALCA, MERCOSUR y ALBA. La Habana : Editorial de ciencias sociales.
Lebow, R. N. (2007). Classical Realism. In T. Dunne, M. Kurki, & S. Smith, International Relations Theories: Discipline and Diversity (pp. 59-75). Oxfrod: Oxford University Press.
McCloskey, D. (2007). The Bourgeois Virtues: Ethics for an Age of Commerce. Chicago: University of Chicago Press.
Mearsheimer, J. J. (2007). Structural realism. In M. K. Tim Dunne, & S. Smith, International relations Theories (pp. 78-91). Oxford: Oxford University Press.
Mersheimer, J. J. (1994-1995). The False Promise of International Institutions. International Security, 5-49.
Mesa-Lago, C. (2007). La economía cubana en la encrucijada: el legado de Fidel, el debate sobre el cambio y las opciones de Raúl. Working paper Nº 19.
Ojeda Medina, T. (2013). Cuba, 50 años de solidaridad con el Sur. In B. Ayllón, & T. O. Medina, La cooperación Sur-Sur y triangular en América Latina. Políticas afirmativas y prácticas transformadoras (pp. 132-152). Madrid: Los libros de la Catarata.
Ojeda Medina, T. (2019). Introduction. In T. O. Medina, La cooperacion sur-sur en america latina y el caribe: balance de una decada (pp. 15-41). Buenos Aires: CLACSO.
Ojeda Medina, T. (2019). La cooperación Sur-Sur de Cuba: autoafirmación y solidaridad. In T.
Ojeda Medina, & E. Echart Munoz, La cooperacion sur-sur en america latina y el caribe: Balance de una decada (pp. 91-103). Buenos Aires: CLACSO.
Oramas, L. (2012). Cuba, paradigma de la cooperación Sur-Sur. Hegoa y Centroamérica por el diálogo. Bilbao.
Petras, J. (2011). Latin America's Twenty-First Century socialism. In H. Veltmeyer, 21st Century Socialism: Reinventing the Project (pp. 11-32). Black point and Winnipeg: Fernwood.
Tavis, J. D., & Silva, M. M. (2008). How Different Disciplines have Approached South-South Cooperation and Transfer. Society for International Education Journal, 45-64.
Tortoló, I. S., Prince, J. C., Ilizátegui, L. S., Salabert, I. A., Soler, M. d., & Naipe, M. C. (2017, March-April). Notes on Barrio Adentro Mision. Tratto il giorno 12 16, 2021 da Revista Médica Electronica: http://scielo.sld.cu/scielo.php?pid=S1684-18242017000200031&script=sci_arttext&tlng=en
Vanaik, A. (2013). Capitalist Globalization and the Problem of Stability: Enter the Newand Other Emrging Powers. Third World Quarterly, 194-213.
Vidal, A. P. (2014). Proyecciones macroeconómicas de una Cuba sin Venezuela. Desde la isla, 24.
Xalma, C. (2008). Cuba: ¿hacia dónde? Transformación política, económica y social en los noventa. Barcelona: Editorial Icaria-Antrazyt.
Image 1: Unknown. (n.d). Cuban medical doctors engaged in an international mission [Photograph]. L'Afrique des idées. Retrieved 01/09/2022 from: https://www.lafriquedesidees.org/developing-cooperation-between-cuba-and-africa/
Image 2: Unknown. (n.d). Mision Barrio Adentro [Illustration]. Fundación Misión Barrio Adentro Barinas. Retrieved 01/09/2022 from: https://www.facebook.com/FMBABarinas/photos/a.1478435122392081/2050505911851663/?type=3
Image 3: Unknown. (2019). Cooperacion Sur-Sur [Illustration]. La voz de Chile. Retrieved 01/09/2022 from: https://lavozdechile.com/buenos-aires-reune-la-conferencia-de-cooperacion-sur-sur/cooperacion-sur-sur/
Image 4: Adàn. (n.d). Ideological cooperation [Illustration]. Cuba Solidarity Campaign. Retrieved 01/09/2022 from: https://cuba-solidarity.org.uk/end-the-blockade/
Image 5: Unknown. (2020). Cuban Medical Internationalism [Photograph]. WPR. Retrieved 01/09/2022 from: https://www.worldpoliticsreview.com/how-the-covid-19-pandemic-is-revitalizing-cuba-s-medical-diplomacy/
Image 6: Latuff. (2020). Medical internationalism as a means for political struggle [Illustration]. Cuba Solidarity Campaign. Retrieved 01/09/2022 from: https://cubasolidarityforum.ie/category/news/