Cuban internationalism – An alternative form of globalization

Cuban Internationalism – An Alternative Form of Globalisation Maria Castro*, University of East London Steve Melluish, University of Leicester Alexis Lorenzo, Universidad de La Habana Corresponding author: Dr Maria Castro, Professional Doctorate in Clinical Psychology, School of Psychology, University of East London, Stratford Campus Water Lane, London, E15 4LZ, +44 (0) 20 8223 4422, [email protected] Abstract This paper looks at how the principles of internationalism have been integral to the Cuban health care system and to Cuba’s cooperation and medical support in other countries around the world. The paper details the range and scope of Cuban health internationalism and the principles that underpin the Cuban approach of long term collaboration: humane care, contextualisation, trans-disciplinarity, respect for collective/historical memory and an ethical stance. The paper focuses on the role of Cuban psychologists who contribute to disaster relief work and gives an example of the Cuban approach in relation Haiti following the earthquake in 2010. Keywords: internationalism, health, psychology, Cuba, cooperation. Introduction ‘The term "globalization" has been appropriated by the powerful to refer to a specific form of international economic integration, one based on investor rights, with the interests of people incidental… No sane person is opposed to globalization, that is, international integration –that is, globalization in a form that attends to the rights of people, not private power systems.’ (Chomsky, 2002) ‘Globalization is an objective reality underlining the fact that we are all passengers on the same vessel, that is, this planet where we all live. But passengers on this vessel are travelling in very different conditions.’ (Fidel Castro, 2000) Internationalism is a desire for greater social, economic and political cooperation among nations for the benefit of all. The underlying belief is that the people of all nations have more in common than they do differences, and that people are both citizens of their respective countries and citizens of the world. This simple idea that nations and peoples should cooperate and co-ordinate approaches to global problems has been behind setting up transnational bodies such as the United Nations and the European Union. Today however, internationalism is often seen as a failed utopian ideal and it is presumed that, when international cooperation occurs, it is only because it coincides with a nation’s own vested interests. The spirit of cooperation implicit in internationalism is in stark contrast to the dominant contemporary discourse around globalisation, which is principally concerned with competition and the promotion of markets and free trade. For many people across the world, particularly those in LMIC countries, this dominant model of economic integration and neoliberal policies has been detrimental and has resulted in an exacerbation of global inequities. Since the first demonstrations against the World Trade Organisation in Seattle in 1999, a broad range of protests and social movements have emerged in response to this form of globalisation and there has been increased global consciousness about the power and influence of transnational corporations (Eschle & Maiguashca, 2005). These global civil movements have also called for resistance to the imposition of neoliberal policies and support for a form of globalisation that is more concerned with democratic representation, human rights, fair trade and sustainable development. These movements have often been referred to as “anti-globalisation” but, as Chomsky (2002) says, this is misleading. These movements are not necessarily arguing against globalisation but for a different form of global integration, for a globalisation from below (Korzeniewicz & Smith, 2001) or outra globalização (another globalisation) that is concerned with social justice and ethics (Santos, 2001). Some have argued that this is a return to the ideals embodied within the older term of internationalism (Teivainen, 2002). While in most of the world globalisation has been the predominant discourse, in Cuba, the spirit of internationalism has endured. This is due to Cuba having offered internationalism as a way forward in creating a different, better world, ‘un mundo mejor es posible’ (Castro, 2003), and perhaps partly also a consequence of its isolation as a result of the economic embargo imposed by the US. Cuba has been an important advocate of greater integration within the countries of Latin America and for South-South (LMIC-LMIC) cooperation instead of the asymmetrical paternalism of North-South (HMIC-LMIC) aid. The principles of internationalism have also been integral to the Cuban health care system and to Cuba’s cooperation and medical support in other countries around the world. Cuban health internationalism Cuba has been internationalist and shown solidarity throughout its history, not just since the Cuban revolution in 1959. Following the revolution, however, internationalism became central to the political will of the Estate and Cuban health internationalism was a key part of its support for anti-colonial struggles. In 1963, the first Cuban medical brigade was sent to Algeria during its war of independence (Piero, 1996). Between 1966 and 1974, Cuba also sent medical missions to Guinea-Bissau, during its liberation struggle against Portugal, as well as to Angola. De Vos et al. (2007:772) reported that ‘28,422 Cuban health workers have worked in 37 Latin American countries, 31,181 in 33 African countries, and 7,986 in 24 Asian countries’ since the early 1960s. Further, from 1963 to 2004, Cuba was involved in the creation of nine medical faculties in Yemen, Guyana, Ethiopia, Guinea-Bissau, Uganda, Ghana, Gambia, Equatorial Guinea, and Haiti. In 2004, following the Asian tsunami, Cuba sent medical support to Banda Aceh and Sri Lanka and, in 2005, following the Kashmir earthquake, a Cuban medical mission was sent to Pakistan. In 2012, Kirk and Walker (2012) reported that there were 38,368 Cuban health professionals working in 66 countries across the world and that, since their inception, Cuban medical missions have involved 135,000 Cuban health workers. In Cuba, the first psychologists graduated in 1964, and with their incorporation to the National Health System a Health Psychology developed (departing from the classical focus of clinical psychology); gradually during the 1970s, psychology was incorporated to all areas of Cuban society, including participation in health, culture and sports missions. Cuba's largest and most extensive medical aid effort has been with Venezuela and has been termed the oil for doctors programme (Feinsilver, 2008). This initiative grew out of the emergency assistance provided by Cuban doctors in the wake of mudslides in Vargas state in December 1999, which killed 20,000 people. It later became an important form of economic support for Cuba, with Cuba providing Venezuela with Cuban doctors and dentists in exchange for Venezuelan oil. While critics have argued that the Venezuelan oil for doctors programme, and other forms of Cuban internationalism, are simply part of a broader game of geo-politics, there have been many examples of Cuba sending health teams to countries that are ideologically opposed to itself. For example, in 1960, 1972 and 1990 it dispatched emergency assistance teams to Chile, Nicaragua, and Iran following earthquakes. Perhaps more surprisingly, Cuba created in 2005 the medical brigade Henry Reeve (named after a heroic young mambí, or Cuban combatant, from the US who gave his life for the liberation of Cuba during its first independence war against Spanish colonialism), in response to hurricane Katrina’s desolation of New Orleans and Southern regions of the United States, although the US government rejected Cuba’s readiness to help. This demonstrates a key aspect of Cuban internationalism: that local problems are seen as global, as problems for all. In other words, peoples’ suffering (regardless of their governments’ politics and policies) is something the Cuban people have an ethical obligation and desire to respond to: ‘Many peoples have benefited from the unceasing, disinterested commitment of Cubans to the advancement of human rights for all worldwide. The blood of hundreds of Cubans was spilt on African soil, as they fought beside their African brothers against colonialism and apartheid. Despite our country’s modest resources, 14, 732 Cubans who collaborate in the health sector and a similar number of Cuban teachers, for a total of 17, 787 professionals, are deployed in the villages, mountains and other remote corners of Latin America, the Caribbean, Africa and Asia, sharing the blessings of medical care, education and culture with the peoples of various nations.’ (Ministry of Foreign Affairs Republic of Cuba, 2004:5) The Cuban approach to internationalism Cubans use the terms collaboration or cooperation (rather than aid). This reveals the different approach and underlying philosophy of Cuban internationalism, which is about working with individuals and communities to introduce a sustainable system of healthcare that can be run by the local people for themselves. To these aims, the Cuban approach to disaster relief could be said to be based on six fundamental principles: 1. Long-term collaboration. The Cuban health teams do not approach disasters as short-term emergencies, but instead take a long-term view, with the local population seen as actors in their own reality (resonant with Freire’s, 1972, critical pedagogy and concientisation praxis). Cuban missions nurture protective factors that help foster resiliency and mitigate the negative impact of future disasters through training and establishing systems of on-going support. 2. Humane care. People are not seen as suffering from a singular ailment but are viewed holistically, within a historical and social frame. ‘We take a holistic approach –we don’t just treat the medical or psychopathological effects of disaster…we try to understand each person within a broader context, taking into account all the factors in their lives’ Dr Alexis Lorenzo, Director of Services at Tarará Hospital and Coordinator of CLAMED’s Mental Health Group (Gorry, 2010:44). 3. Contextualisation. Every disaster is unique to a moment in time, so the response has to be designed for the specific context, including multiple historical, economic, social, cultural and environmental factors (Lorenzo, 2009). 4. Trans-multidisciplinary approach. This means the Cuban health team relies on knowledge-sharing amongst actors at all levels –local, regional, and international– and across sectors and mental health disciplines (Gorry, 2010). 5. Respect for the collective, historical memory of the disaster-stricken area. Historical memory (a term widely used in community and liberation psychology, e.g., Martín Baró, 1994) is at the roots of collective identity as a base to learn from the past, critically assess the present and project possibilities for the future. It is vitally important that popular knowledges (as there are a multiplicity of valid knowledges, rather than one body of knowledge), local beliefs, religious practices and personal experiences are taken into account, and that these knowledges are integrated into the mental health response. As a way of enacting this principle, unlike many foreign aid workers, Cuban health workers also live within the communities where they work, so are visible not only in their health work but also in their daily lives as they queue to get food or water from the local well. 6. Ethical stance. In Cuba, access to health care is seen as fundamental human right and is embedded in the Cuban Constitution (9th and 50th Articles), as is a responsibility Cuban citizens have in relation to active engagement in the planning and delivery of services (45th and 64th Articles). Hence, a core aspect in the training of Cuban healthcare workers is ethics and the ethical responsibilities of health care workers. These principles constitute an ethical approach that is at the core of the training of health professionals offered by the Latin American Medical School (Escuela Latino Americana de Medicina, ELAM), which was founded in Havana in 1998 and is now the world’s largest medical school. Huish (2008) reported 11,500 doctors from 29 countries (including the US) had trained at ELAM. Students are selected from impoverished backgrounds, mostly from countries across Latin America and LMI countries, as it is considered that they will have more commitment to working in poorer communities than their wealthier peers. The Cuban state covers the tuition costs, accommodation, sustenance and a small stipend over the six-year training but students are required to make a moral commitment to return to their countries and work with the underprivileged and those most in need (Huish & Kirk, 2007). This approach to ethical training and a commitment to those most in need has reduced the brain drain effect seen in many poorer LMIC countries where once qualified, medical professionals often leave to seek better paid jobs in wealthier nations (Shah, 2006). The distinctiveness and success of the Cuban model can also be seen in the recent involvement of Cuban healthcare workers in Brazil. In 2013, President Rousseff announced that thousands of Cuban doctors would be hired to address the lack of healthcare personnel in hundreds of cities across the country. Local Brazilian doctors criticised the initiative, claiming that local doctors should be hired instead. However, after a hiring programme open to doctors from Brazil and other countries only managed to recruit fewer than 1,500 professionals out of the 15,000 posts offered, the government signed a deal with Cuba to hire 4,000 Cuban health professionals. These posts were to work in poor rural areas in the north and north east of the country, where there is the greatest health need and the largest population exposed to major health risks, but zones where Brazilian and other medical staff did not want to go. The Brazilian government stated that ‘Cuba is the only country in the word capable of sending a contingent of a 1,000 doctors in rapid time to areas of most need’ (Ravsberg, 2013). Disaster relief – the Cuban psychology approach in practice Cuban psychologists have been an integral part of Cuban internationalism and have formed part of the Cuban response to disasters. In preparing psychology teams, there are a number of stages: Selection The first stage is selecting psychology personnel. There are two selection points, the first one made by Cuba and the second by the receiving country. The first criteria for Cuba to select psychologists are that they are valued and respected professionally. They must have either a background in scientific research or good clinical and teaching skills. However, their years of experience, specific expertise or affiliation to particular values are less important than their commitment to completing the mission. The initial selection will also look for: good physical health; psychologists who can represent the profession well; professionals who have some knowledge of the culture or, at the very least, do not have strong opposing beliefs to those of the country to which they will be going. Finally, there is a legal framework (an agreement to sign specifying the rights and responsibilities of the professional and any others involved) and a medical check (vaccinations and so on). Preparation Once psychologists have been selected for a mission there is a period of preparation. Initially this is mostly technical and cultural, providing information about the country, its social, historical and current contexts, and other international aid organisations both nongovernmental organizations (NGOs) and United Nation’s involvement in the area. In the process of preparation, psychologists are trained in human rights law; because in work both generally and in disasters, the psychologist will have to attend to human rights at a micro-political level. The final preparation is a briefing centred on the particularities of work set out in the mission and, when required, the teaching of the language or dialect used in the area where the work will be carried out. The brief involves an experiential preparation, which includes role-plays, visualisation, and in-situ training under supervision. The preparation responds to lessons learnt from previous missions, such as the awareness that in international collaborations the selected professional(s) can create a problem; for example, they can be adversely affected by what they encounter. Necessarily, there needs to be a reflective and progressive ethical-cultural-humane preparation (Lorenzo, 2009), which goes beyond academic psychology. Throughout the history of Cuba as a nation, this has been the compass of Cuba’s historical path and a symbol of Cuban identity, particularly since the Revolution. This ethical-cultural-humane preparation is not only present in professional endeavours; it is seen also, directly or indirectly, in each aspect of daily life. An ethical-cultural-humane preparation for psychologists is engendered not only through psychological knowledge and skills; it involves the integration of universal, national, and even familial, ethical values. This preparation is the product of a progressive training process throughout the lifespan learning cycle, from the early stages of personality development, achieved indirectly, in proximal and community contexts, through schooling, mass media and so on. Thus, knowledges and skills learnt in higher education and professional training are not isolated from the individual’s personal history. The development of explicit learning, described today as competencies, is dialectically integrated with the person’s lifespan and personality as a whole. In this way, this process is permanently ongoing and, at the same time, phased with different levels of preparation, from basic, to advanced, to a higher level we call professional. The mission During the mission, the psychologist continues to receive their salary and benefits back home; however, at the level of the country where they are on the mission, there may be different financial agreements, from no fees to fees exchanged by both countries. The rationale for each particular mission is based on the demands for relief from the country in need. For example, in 1990 (four years after the actual disaster), Chernobyl requested aid from the international community, and Cuba tailored a program to this demand. First, people affected by the radiation were given medical care in Cuba (benefiting over 25,000 people over the last two decades), then, Cuban medical teams went to the Ukraine. The approach taken by the teams was a creative application of the model the Cuban Revolution utilised to take to the rural areas all basic services, i.e., culture, social welfare and education. Depending on the country, the model of intervention will vary. Generally, it is carried out side by side with local professionals; however, this may not always be possible, as there may not be equivalent professionals locally or they may not be in agreement with the mission. Where a link is established with local professionals, specific theoretical and methodological frameworks have to be negotiated, making explicit how these can be ethically applied and taking into account that any model will evolve over a number of stages: 1. Professional preparation. 2. Preparation for the task. 3. Engagement with the task as a pilot. This allows the redesign of the task following interaction with local professional, as well as any personal knowledge the psychologist may bring, based on local knowledge and historical memory – this interaction is necessary for the work to be ethical, humane and professional. 4. Implementation of the redesigned project. Evaluation The implementation of the redesigned project is accompanied by ongoing evaluations, which are written and shared with all those involved. A final evaluation, alongside supervision and systems of help and self-help, is also undertaken to evaluate the outcomes against the initial agreement. As part of the involvement in the mission, and to aid the system of auto-evaluation and evaluation of the practice, psychologists keep a written memory from the outset. This is used as the basis for future work in the area as well as for presentations and publications. Endings and sustainability The ending of the mission will take place according to the agreement entered into. Depending on the practices of the country, there may be a legal framework around this. The ending is often more difficult than the beginning of the mission, particularly for the personnel involved, therefore, careful preparation is made for the closing. Ultimately, it is important that psychologists are self-aware and also self-care, as they will have families and jobs to return to back in Cuba a personal closure is important. The Cuban approach is all about developing a long-term vision and about how the project will be continued by the local communities once the collaboration ends. Thoughtfulness about how the records and any data will be kept, for the community and for teaching, is also an important part of the ending of a crisis response and setting the basis for local and sustainable action. An example of the Cuban approach – Haiti’s earthquake Cuba’s response to Haiti’s earthquake in 2010 provides a good example of this long-term involvement and the revisiting and renegotiation of tasks. Since 1998, Haitians have been trained in Cuba to become health professional, to date 889 have become medical doctors (Marimon, 2014). Concurrently, also since 1998, Cuban led health teams, including psychologists, have been involved in Haiti providing health care services. When the earthquake struck in 2010, these teams turned to emergency services, with further reinforcement of health professionals from Cuba. However, once the immediate crisis had passed, Cuban teams transferred back to offering a comprehensive health programme for the long-term (Gorry, 2010). At the time of the earthquake, Haiti was already immersed in a chaotic situation in many regards, heightened as a result of the earthquake. Thus, Haiti had little capacity to respond, placing a pressing demand on action from international teams, which were required to be prepared for such circumstances, not only in relation to technical aspects but also in their capacity to re-adapt their ethical-cultural-humane training in disasters, to insert themselves in Hatians’ every activity respecting the historical memory of the Haitian peoples. In the case of Cuban cooperantes (Spanish noun for the action of cooperating) it was possible to fulfil these requirements because, as stated earlier, these principles are explicitly and consciously applied in life, in institutional education and professional training. One aspect that has been characteristic of Cuban psychologists in disaster situations and other spheres of international cooperation, is that professional practice is closely linked to the psychologist’s own contexts, hence, the offer or suggestion of a scientific methodology is never going to be separate or divorced from these contexts; the personal and professional are inextricably linked. Although Cuban teams did not have tents, hospitals or modern technologies, their ethical-cultural-humane preparation facilitated alliances and mutual understandings and comprehension. This preparation allows the psychologist (and any other professional) to re-adapt and work in companionship, instead of interventionism, in this kind of international mission. In our view, professionals and, particularly, psychologists in disaster situations must be ethical and humane and respect the culture in which they are working in their practice, as the efficacy and success of the collaboration will not be due to technology or finance but to the human factor. Furthermore, for the Cuban professionals in Haiti there were a huge breadth of personal, group, family, institutional, community and territorial experiences, both nationally and internationally, in cooperation activities and mutual help in situations of emergency and disasters, from which they could draw on in their work. Cuban cooperantes integrate (and continue to integrate) themselves in the daily life and dynamics of the population in each area of Haiti, offering general to specialist services, 24 hours a day seven days a week, in all the Departments of the country, independently of living standards or material conditions available. This support takes place within a constant dialogue with institutional and community authorities, so that every activity and service responds to the local felt needs and active participation is stimulated, with the local population being active subjects in the process of post-disaster recovery. In turn, this allows the gradual training and capacity building of Haitian personnel, institutions and communities, so eventually they are able to guarantee the continuation of services themselves. The ethical-cultural-humane preparation already referred to, and the respect for the historical memory of the Haitian peoples, are taken into account to protect the health and humanity of the local population, and of the cooperante. Promoting individual agency to increase sustainability was, and still is, key to the collaboration with Haiti. This approach has allowed Cuba the long-term, ongoing engagement in this internationalist programme of cooperation and solidarity. The Cuban health teams ran workshops with local leaders, community members, local NGO staff, and other stakeholders to develop psychological and social resources and so provide a sustainable base for community rebuilding; targeting key individuals served to have a multiplier effect on the wider community. As Dr Lorenzo explained: ‘the more prepared a person is, the more they can help. Our goal was to provide people affected by the earthquake with psychological and social resources to be able to start rebuilding their lives. In post-disaster situations, water, food, housing, and medicine are of primary importance, but these things alone will not enable a person to reconstruct their life’ (Gorry, 2010:45). Reflections The Cuban system has, thus, developed a cost effective (WHO, 2011), pragmatic, highly ethical and sustainable healthcare system, both for its own people and for those it assists through its international cooperation in other countries facing disasters. Psychologists have been a key part of this international cooperation and play an important role in negotiating with local professionals. For any early response system to work well, psychologists need to be trans-multidisciplinary, relating to, and respecting (and integrating with professional knowledge) the popular knowledges and historical memory of the people with whom they are working. This necessitates a systemic, interactive and collaborative working model that incorporates individuals, families, groups, institutions and communities. From our perspective, a key idea to keep in mind is that a help that helps is ethical and humane, it does not think it is in possession of an ultimate truth and is sensitive to the particularities of the context, such as the local knowledge, practices, skills and identities. In the Cuban approach, this help that helps is observed, for example, in the way that the Cuban mission does not impose a work schedule or a theoretical or methodological approach but remains sensitive to the receiving country and its own systems, traditions, and religious and spiritual practices. The role of psychologists in each mission often goes beyond their expectations and beyond the preparations they have made, as they transition through different moments of adaptation. Disaster situations are not static but, rather, are formed and developed as processes and sometimes the reality of the project and the initial ideas about it do not match (Lorenzo, 2009). In such situations it is the capacity to re-adapt, in the sense of doing something again but differently, but also doing differently something new, that is the measure of the project’s success. In every relief mission there is something of a honey-moon period, when everything is perfect, but as it goes on it becomes a matter of doing all that can be done and doing all that can be done better. Hence, being involved in a mission provides endless opportunities for learning and, in this sense, the psychologist is engaged in (an often intense) ongoing personal development. Whilst there is an associated pressure in this continued demand, it is a welcome challenge because the Cuban psychologist is doing something of worth, out of a will and desire to do it, but also out of a love for humanity. ‘Let me say at the risk of seeming ridiculous that the true revolutionary is guided by great feelings of love… We must strive every day so that this love of living humanity will be transformed into actual deeds, into acts that serve as examples, as a moving force.’ (Ernesto ‘Ché’ Guevara, 1965:15) References Chomsky, N. (2002). On Escalation of Violence in the Middle East. The Croatian Feral Tribune, May 07, 2002. http://www.chomsky.info/interviews/20020507.htm Castro, F. (2000). Text of the speech given at the opening of the South Summit in Havana, 12th April, 2000. http://archive.8m.net/castro.htm Castro, F. (2003). El símbolo de la globalización neoliberal ha recibido un colosal golpe [The symbol of neo-liberal globalisation has received a great dent]. 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