The Salud International (SI) team were invited to visit the Cuban Medical Brigade in Haiti in December 2003. Our mission was to see, at first hand, an example of the work of Cuban Medical Collaboration, and of the Cuban doctors working voluntarily in over 60 poor countries, and importantly to develop ideas of practical solidarity with the brigades through the Cuban Health Workers Union (SNTS). We were said to be the first British to apply for visas at the Haitian Embassy in Havana, and according to the visitors book we signed in the Haitian capital Port au Prince, also the first foreigners to officially visit the brigade in Haiti.

Having worked with the SNTS since 1995, we were well aware of the successes of the Cuban health service, the problems created by the US blockade of Cuba such as the difficulty in obtaining medicines, medical equipment, and basic items such as cleaning materials for the hospitals. We also knew of the difficulties faced in the everyday lives of Cubans caused by the blockade. We were aware that large numbers of British GPs had visited Cuba to learn from their remarkable successes in the field of Primary Health Care. No surprise, therefore, that we were very interested to learn how Cuba was able to help other poor countries develop health care systems based on the successful Cuban model when they themselves were having to deal with the consequences of a damaging 40 year old economic and political blockade by the superpower neighbour to their north.

Haiti was the world’s first black republic and the western hemisphere’s second country to throw off the yolk of colonialism (the other being the USA). Its history is one of poverty, corruption, coups and US intervention. After years of the Papa Doc Duvalier dictatorship, a painful transition to some sort of democracy was eventually brokered, although the Tonton Macoute, (Duvalier’s personal armed militia), were never disarmed leaving 150,000 unsupervised firearms in the country. It appears that they only handed over their dark glasses! President Aristedes was elected to power but the country was awash with armed gangs.

The country has the highest indicators of poverty outside of Africa, its infrastructure all but non existent and the land largely deforested. Sewage runs openly through the tracks in the shanty slums around the capital. Water is unsafe to drink and electricity nonexistent in many areas. The public hospitals, where they exist, were unable to deal with basic demands and staff, more often than not, fail to turn up for work in the hospitals. Public health and primary health care were non existent. Then in 1998, the island of Hispanola that Haiti shares with its neighbour the Dominican Republic was hit by Hurricane Georges. Thousands were killed, whole villages were swept away, hundreds of thousands were made homeless and scores of thousands of livestock were killed. It was as a direct result of this that Cuba sent its medical brigades to both Haiti and the Dominican Republic.

At the time of our visit to Haiti, intense violence between supporters and opponents of Haitian President Aristedes was increasing. We were told that it was not safe to walk the streets of the capital Port au Prince or in the other main centres. Consequently we visited the Cuban Medical Brigade’s national centre in the University Hospital in Port au Prince, the brigades for the West Department including the capital and Kenscoff, and the brigades of Artibonite Department in San Marco and Gonaieves. We also visited the public hospital in Port au Prince and met its Haitian Director as well as the Head of the Cuban Medical Brigade and the Cuban Ambassador to Haiti. We were unable to visit Mermalade in the mountains of Artibonite, the Medical Faculty in Port au Prince or Cap Haitien in the north due to the worsening security situation. It was clear to us that the Cubans took a neutral stand on the violence, regarding it as an internal Haitian problem.

In the midst of all these difficulties, we met the Cuban Medical Brigade. It had arrived in Haiti in early 1999. Cuba, along with many other countries sent doctors to help the survivors of hurricane Georges. After a while, most other aid agencies departed, but the Cuban doctors remained, despite the fact that no diplomatic relations existed between the two countries. Cuba appealed to the rich countries to send technical and pharmaceutical aid, but this appeal fell on deaf ears. Only one small French NGO worked directly on a Cuban project in the north of the country although the Cubans do cooperate with Medicins Sans Frontieres, a number of church based charities, the Pan American Health Organisation and Japanese and Canadian NGOs. However, only the Cubans are prepared to visit Haitians in their homes because of the risks and hazards involved.

The Brigade in Haiti comprises 575 doctors and health professionals, and operates the Integral Health Programme, based on the Cuban domestic model, as do the brigades in more than 60 other countries. It operates in nine Haitian Departments covering 70% to 80% of the population. Their aim is to provide good or improved health care for Haitians and to lower mortality rates. Their work starts with a comprehensive analysis of the health situation, of the various risks to health and the existing resources. This is followed by a strategy to remove the risks that can be dealt with such as ensuring clean drinking water, changing diet, improving sanitation and sewage and by making visits to every house in the locality. This would probably be the first time that most Haitians have been visited by or even met a doctor. On their visits, they see every member of the household and make basic health checks. They then organise potential patients into circles or groups for the elderly, those with hypertension, pregnant women, adolescents and children to discuss and identify risks to their condition and find remedies and solutions. Some of these may be as basic as exercise for those with hypertension or elderly, prenatal examinations, use of condoms, and family hygiene, and others involving medical solutions including the use of surgery. If a Haitian patient needs a specialist treatment they are flown to Cuba free of charge to be treated.

The emphasis of the Brigade is on prevention of disease, eradication of the causes of health problems and the promotion of good health. In particular, the Cubans tackle the causes of high rates of infant and maternal mortality. Having one of the worlds lowest rates on infant mortality back home, the Cuban doctors are well placed to deliver the lower rates that prevail where the brigade members work. When they arrived, the Cubans found an infant mortality rate of 80 per 1000 births. Today the rate, in areas where Cuban doctors are based, is down to 5 per 1000 or less. Over the last five years, Cuban doctors have made 5 million home visits. They have been scrupulous in keeping a statistical and scientific record of their work. They have established a vaccination programme for Tetanus, Chicken Pox and Polio, covering 300,000 children so far.

The local brigades are composed of mainly young people, many of whom studied in the same medical school and year, along with some very experienced professionals. They comprise specialists in general medicine, internal medicine, orthopaedics, neurosurgery and general surgery, paediatricians, gynaecologists, obstetricians, technicians and other professionals. In each brigade there are commissions for scientific advice, care of the gravely ill, quality, security, finance, discipline and emulation. The brigades operate on a pyramid structure with a national brigade that co-ordinates the work across the country plus brigades based on the country’s Departments in addition to local brigades in small towns and localities. Many of the brigades operate without electricity and often without water. Most Cubans learn to speak Creole – the Haitian patois - within a couple of months. They receive a small stipend, but we learnt that they use much of this to buy medicines and equipment to treat their Haitian patients. They serve for two years and return home for one month after the first year.

Because of the lack of medicines in Haiti, the Cubans have introduced their speciality of traditional and natural medicine, honed to a fine art as a result of the US blockade that prevents Cuba buying medicines. Medicinal plant culture was an interesting feature of the brigades work in Haiti

Each brigade is broken down into smaller units and we met the team based in Port au Prince that covers a population of about 2.6 million. There were 30 doctors, 18 nurses and technical staff and 2 engineers. There are also Cubans training Haitian medical students at the main hospital and the medical faculty. Confirming that they do keep meticulous statistical information, they told us that in 2002/3 they carried out 155,896 home visits, 3,707 surgical operations, 21,470 applications of traditional and natural medicine and they estimate that they directly saved 946 lives. Infant mortality rates had fallen from 80 to 4.4 per 1000 births in their patch with a similar fall in the rate of maternal mortality. The main diseases they are countering were tuberculosis and malaria as well as HIV/AIDS. The rate of HIV infection is not known as the test to confirm HIV positively is too expensive, but the brigade estimates that in some parts of Port au Prince, the rate is as high as 40% of the population. They have also found rates of sexually transmitted disease infection as high as 80% among pregnant women. For the elderly, hypertension is a serious problem due to the excessively high amount of salt added to the corn porridge that is their staple diet. There are also major problems with infected drinking water, sewage and refuse across Haiti.

With Jorge, a Cuban Neurosurgeon, we visited the main public hospital in the country, the University Hospital, which could only be described as a study in chaos. The emergency department was a vision of hell on earth, people everywhere sitting on the floor or crammed into beds, bodies in states of distress and misery more like a war zone than an accident and emergency unit. With well over one hundred such emergency patients, there was only one Haitian medical student and one nurse.

We visited the children’s neurosurgery ward where Jorge worked. Again, the conditions were distressing with cots crammed everywhere and mothers providing nursing care. There are many children with encephalitis and awful tumours. Jorge has performed many operations on children, but without the plastic ‘shunts’, a form of drainage following surgery, he is restricted in how many he can perform. He buys some out of his meagre stipend. Jorge is the only neurosurgeon in the country but is currently training a Haitian surgeon. We learn that in many wards and departments, the Haitian medical staff, go home at four in the afternoon. Consequently there is no care or treatment after that time. The Cubans are trying to change this by visibly demonstrating high moral principles and a disciplined work ethic.

The Cuban Medical Brigade in Kenscoff was based in a large house in the mountains above Port au Prince. This is where Graham Greene’s book ‘The Comedians’ is set, and little seems to have changed forty years on. The house is also a clinic in a tropical forest. There are 3 Cuban doctors and 1 nurse serving the rural community and their dedication is palpable. There are 530 homes in this area and they have visited and assessed the medical conditions of all who live there .The main problems they have identified are bad drinking water, high risks for pregnant women, hypertension, rats and mosquitoes. They have developed action plans for each problem and these are displayed on the wall of the clinic. This year there have been 67 births in their care with no deaths of baby or mother. They are currently training local people to become midwives. Outside they have planted medicinal plants and they are training local people to grow plants that can help with their medical treatment. In the corner of the house was a ‘patriotic corner’ with the Cuban flag, a bottle of rum, pictures of their family etc to remind them of home.

The following day, we were to go to Artibonite Department to the north of Port au Prince. We were collected by the brigade leader, Luis, in a Haitian Secretary of Health land cruiser, loaned to the brigade. On the road out of the capital, near the docks, is a massive teeming slum area with people living in squalid shacks or, at best in salvaged containers and at worst in what pass for streets, with raw sewage running through the whole area. The thought of what diseases prevail there is frightening. These were far worse than the squatter camps we had visited in South Africa in 1994, where at least there was some form of organisation and politics. Here there is just chaos, squalor, despair and disease, and an atmosphere of menace and danger. We could now understand why the World Health Organisation had declared that Haitian bank notes were a health hazard because of the potential for transmitting disease. AIDS is endemic, as is typhoid, malaria, tuberculosis and chicken pox.

We visited the local Cuban Medical Brigade in St Marco, a small ramshackle town on the main north/south road in Artibonite Department. Seventeen Cuban doctors and nurses worked here covering the local community spread over a wide are. The story was similar to that in Kenscoff, except that AIDS was a far bigger problem here.

From St Marco we continued north to Gonaives, the main town in Artibonite, travelling across the fertile Artibonite valley with its paddy fields. In the Cuban brigade headquarters, where they work and live without electricity, telephone or other means of communication, we learned of their successes. We learned of the thousands of families they had visited, the action plans they were implementing, the lives they had saved and their plans for the future. Sanitation was one of the biggest health hazards here. That was until the violence started here in earnest in late 2003. Gonaives appeared to be the centre of the violence with opposition groups trying to prevent President Aristedes from visiting on the anniversary of colonial liberation from France. It was the Cubans who staffed the local hospital and who took the bullets out of the wounded and dying. The violence had halted all of the Cuban home visits for 25 days. We learned that the opposition had shot dead twenty two people in the town including policemen and children. However, we were assured that the Cubans did not take sides in this conflict and were respected by both sides.

We witnessed the truth of this the following day when we were travelling in the government supplied land cruiser with the Secretary of Health logo on the doors. Luis had covered the vehicle in Cuban flags and it soon became clear why. Whist travelling on the main north/south highway, we were stopped at barricades of burning tyres by an angry opposition crowd of about 500, armed with guns, petrol bombs and machetes and carrying an upside down US flag. As we tried to reverse out of this, the crowd advanced on us until we they recognised the Cuban flag. We were then escorted through the barricades and arrived safely at the Cuban HQ whilst the gunfire started. Cuban doctors then made their way to the town’s hospital as they knew they would be needed as the only staff there to help save the victims of the gunfight, however, there were some fatalities from gunshot wounds because there was no blood bank, and consequently no possibility of blood transfusion.

This example of the respect awarded to the Cubans was born out by later incidents.

Just before we left Gonaives, one of the doctors was confirmed to be suffering from dengue fever. There had been other cases of dengue and malaria among the Cuban doctors and this underlined the risks that face them in their day to day work in Haiti.

It was impossible to continue north for safety reasons, so we returned to Port au Prince where the armed opposition was demonstrating on the streets. The following day, supporters of President Aristedes took to the streets in even greater numbers. Despite the dangerous situation, we were, however, able to discuss the programme and successes of the brigade with both the Cuban Ambassador and the Head of the Cuban Medical Brigade. Their most impressive achievement is that as at December 2003, they had saved 81,856 lives since they had arrived in 1999. This excludes potential lives saved through reducing infant and maternal mortality rates.

The ambassador wanted to stress that the key to the Cuban mission was sustainability. To sustain their work, they were training Haitians to take over from the Cubans. There were now 632 young Haitians studying medicine at the Caribbean Medical School in Santiago de Cuba. These young people were from the teeming slums of Port au Prince and the poor rural areas. In addition, 161 young Haitians had qualified in Integral General Medicine, having been trained by Cuban teachers at the Medical Faculty in Port au Prince. These had all been selected by the Haitian authorities from the poor areas where the Cubans were working and they will all return to those same areas for at least nine years to replace the Cuban doctors.

Three things impressed us most. The first was the whole concept and organisation of these brigades. That a small country like Cuba could provide the skilled human resources to change and save the lives of thousands of people in more than sixty countries. We could not think of another country that could do this.

Second was the selflessness and courage of the Cubans in Haiti. Mainly young people, they are truly heroes.

Third was the love we saw displayed by ordinary Haitians for the Cuban doctors. We witnessed this not only from the armed opposition in Gonaives, but from emigrants who had returned home from the US, from hotel staff, from Haitian doctors and ordinary Haitians.

We were later to learn a lot more about all three of these factors from our subsequent visit to Honduras. But within a month or two after leaving Haiti, former army leaders in exile had crossed the border from the Dominican Republic into Haiti to strengthen the opposition and depose President Aristedes. The violence escalated, US and French troops arrived and all aid agencies left the country - except the Cubans. After the French troops closed the main hospital in the capital, the Cubans set up the country’s only working medical facility in a canteen in Port au Prince supported by the International Committee of the Red Cross and the Pan American Health Organisation. Despite the change of government, the Cuban Medical Brigade continued its work without injury or loss of life, another testament to their heroism and to the affection shown to them by all Haitians.

Infant Mortality under one year old, January to November 2003.

In areas without Cuban Medical Collaboration - 80.3 per 1,000 live births

In areas with Cuban Medical Collaboration - 28.8 "      "           "

In areas without Cuban Medical Collaboration - 135 per 1,000 live births

In areas with Cuban Medical Collaboration - 57.5 "        "            "

In areas without Cuban Medical Collaboration - 523 per 10,000 births

In areas with Cuban Medical Collaboration -262            "        "        "

Surgical operations since the Brigade arrived – 56,800 including 21,237 major operations and 4,588 elective surgical operations.

137,161 (15%) more medical consultations in 2002 then 2003

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We visited the Latin American School in Havana in November 2004, although I had first been here in 1999, when it was first opened. At that time, I was with the delegates at the Cuban Health Workers Union 8^th Congress, who were being introduced to the school. Pedro Ross Leal, General Secretary of the Cuban TUC (CTC), was explaining to the delegates, the role of the school and Cuban Medical Brigades in Latin America and Africa. Five years later, I was revisiting the school having visited a brigade in Haiti and about to visit the Cuban Medical Brigade in Honduras and learned of the work of the Cuban Medical Collaboration programme.

We were hosted by Victor, the head of protocol at the school, who told us that the school was founded on the concept of Love and Solidarity and the principles of Simone Bolivar and Jose Marti. We learned that the Collaboration programme had started in 1963, when a Cuban Medical Brigade was sent to Algeria following an earthquake. He told us that in 1959, at the time of the success of the revolution, there were 6,000 doctors in Cuba, but 3,000 of them left for the United States. Four years later, they were able to send medical collaborators to Algeria, after forty years, more than 31,000 Cuban medical collaborators had served in Africa. At present, there were 2,000 in Africa, living and working with the population.

The school was founded in 1998, following the devastation in Central America caused by Hurricane Mitch, in what previously was the Cuban Naval Academy – a real example of ‘turning swords into ploughshares’. Its objective was to train medical students from poor areas of Latin America and Africa, free of charge, so that they may return to their homes in those same areas where Cuban doctors are working, and replace the Cubans – the ultimate sustainability. The Cuban Medical Collaboration programme also trained medical students in Medical Faculties in their own countries. So far, 2,700 Africans had qualified as doctors and some are now serving as ministers in their own country. The programme continues to establish medical facilities in Africa. To combat HIV/AIDS in Africa, Cuba has made an offer to the United Nations to send 4,000 doctors to Africa if the rich countries could provide material resources.

There were currently more than 8,000 students at the school from twenty four countries in Africa and Latin America with an annual intake of 1,500. Each country has a contract with Cuba. For the students, the school is totally free, textbooks are guaranteed and the students receive an allowance of 100 pesos per month. In addition to the medical school, the students are spread among 21 Cuban medical institutions for four years and qualify after five years. They also work in primary health care.

Sometimes, the students co-operate on a medical campaign in one of their own countries. For example, Honduran and students of other nationalities returned to their country to work on a joint Honduran/Cuban campaign against an epidemic of dengue fever. The medical school nominated 480 students to go to Honduras for one month. They were part of a pest control programme including fumigation and other processes to exterminate mosquitoes. The students made such an impact that the Honduran government sent a commemorative plaque to show the nation’s gratitude to the school. This year, 215 Honduran students will graduate from the medical school in addition to others at the Medical Faculty in Honduras. The students also do fifteen days voluntary work annually in the field of health and social work in Cuba or in their own country.

The parents of the students, in their home countries, look after the Cuban doctors in their locality have formed Parents Associations. Every year they send representatives to the medical school to celebrate with other associations from other countries. Many problems are discussed and resolved at these meetings and the parent’s associations are updated on new developments.

We talked with a few medical students at the school.

Josue from eastern El Salvador had been at the school for one year. He found his way to the school through an organisation in his country that awarded student scholarships.

For Vanesa from Suchitepeque in coastal Guatemala, previously affected by civil war, there was a Cuban Medical Brigade in her locality. "I always wanted to be a doctor, but when I saw the humanitarian way the Cuban doctors worked, I decided to apply to be considered for a place at the Latin American Medical School. I was so pleased that I was selected by the local community."

Alex from Honduras had a different experience. He was a Garifuna living in the Department of Gracias a Dios on the northern Mosquito coast. "My father was a farmer. We had a smallholding and some cattle. Hurricane Mitch devastated our region and we lost everything and the situation was very difficult. Then Cuba decided to help the five Central American countries badly affected by the hurricane – Honduras, Nicaragua, Guatemala, Costa Rica and El Salvador. In my country, the government selected students for the school from the poorest families through the health regions. I’ve been at the school for two years and will go back to my home area when I have qualified. I’m from the Garifuna ethnic group and we were always short of doctors. Now we can change that. I really like this medical school. Whatever we need is supplied, the teaching is very good and I love the social life."

We also met Yusei, Michael and Gerardo, workers at the medical school.

In the grounds of the school was a sculpture called ‘Dreams’. It had been donated to Cuban President Fidel Castro for the school by the sister of Yoko Ono. Five years after witnessing the opening of the Latin American Medical School, we could surely say that this was the School of Dreams.

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We left Havana for the Honduran capital Tegucigalpa. The Latin American Medical School had left a burning impression in our minds with the slogan of love and solidarity ringing in our heads. Honduras has a fascinating history, but my memory of the country was of a giant US military base where the Nicaraguan ‘contras’, anti government insurgents, were armed, trained and infiltrated into neighbouring Nicaragua. We were met by Pedro, a deputy head of the brigade and taken to the headquarters of the Cuban Medical Brigade in Honduras where we were welcomed by brigade chief Efren, who gave us a presentation on the history and work of the brigade.

The Cuban Medical Brigade in Honduras arrived on the 3^rd November 1998 as a direct response to the devastation caused by hurricane Mitch. The hurricane paused just off the coast of Honduras and then moved inland dumping its entire load of water on the country washing away bridges, livestock and roads leaving up to 20,000 dead or missing. Along with other countries, Cuba sent doctors to help, but the Cubans stayed on, at first in the inaccessible areas of the north of the country.

Unlike Haiti, Honduras has a health infrastructure that covers around 70% of the population. There is a state health sector, a private sector, and small social security and military sectors. The state Health Secretariat has 4224 hospital beds, the social security sector 593 and the private sector 1400. The number of beds in the military sector was unknown. Many parts of the 18 Departments (provinces) and the 9 health regions have little or no medical cover. Consequently, the work of the 280 members of the Cuban Medical Brigades is focused in these remote, often inaccessible or dangerous areas, often lacking electricity or water. In addition Cuba provides free medical training for more than 600 young Hondurans in the Latin American Medical School in Havana and medical teachers at the Honduran Medical School in the capital Tegucigalpa. These arrangements are governed by joint agreements between the Honduran and Cuban governments

We met the Metropolitan brigade in the capital Tegucigalpa which comprised cardiologists, paediatricians, epidemiologists, as well as those specialising in general medicine and laboratory technicians. They undertook 230,000 consultations and house visits in 2004, and identified the main health problems in the capital as dengue fever, respiratory problems, and diarrhoea. As an example of their work, they explained that

they had evaluated the scale and origins of dengue fever outbreaks and had trained four Honduran technicians to lead a campaign to fumigate and eliminate the mosquitoes spreading the disease, and had trained medical students in prevention methods. As far as respiratory problems and diarrhoea was concerned, they would treat the conditions but then focus on prevention and the promotion of health

From Tegucigalpa, we travelled through Francisco Morazon and Comayagua to Santa Barbara Department where we were to see the typical way of working for the Cuban doctors in Honduras. They were working on their own, sometimes with a Honduran doctor or nurse, in some of the most remote, isolated and inaccessible areas of the country. Usually they would be based in a clinic that had previously only been open part time but was now providing twenty four hour cover. Most clinics were without electricity making the work of the doctors very difficult. The following examples can hopefully explain the impact that the presence of the Cuban doctors has had on the ordinary lives of Hondurans.

Zombrano, in Francisco Morazon, with a population of 5,478, had a government clinic operating for three hours each weekday. Now it operates eight hours each day and provides twenty four hour emergency cover. We met Giselle, a 26 year old Cuban doctor from Havana. She worked with a Honduran doctor who studied in Havana and told us that the health collaboration had had a big impact in this area. They have conducted vaccination campaigns to eradicate tuberculosis, polio, diphtheria, whooping cough, tetanus, influenza, hepatitis B, rubella and measles. They also had programmes for prevention and health promotion, including improving sanitation. Patients paid a small charge to visit the clinic, but all medicines were free, as were house visits.

We stayed overnight in Santa Barbara town, and were made guests of local Hondurans. Their hospitality was exceptional, considering it a duty to assist friends of the Cubans. We met with Jenry, from Pinar del Rio, who was the head of the brigade for the health region comprising Santa Barbara, Cortes and Yoros Departments and also with Isadora, who we had previously known as a the Provincial Secretary of the Cuban Health Workers Union in Holguin Province. She was responsible for the brigade in the Department of Santa Barbara. In the brigade HQ in Santa Barbara, we met both Cuban and Honduran doctors. They worked very closely together and we were very impressed with their obvious mutual respect. There were also local Hondurans who were good friends of the Cubans and who insisted on accompanying us the following day and interpreting for us.

Ilama with a population of 8,567 had a clinic for urgent cases with similar cover although previously it just had the one nurse. Patricia, from Havana, was the Cuban doctor working with a Honduran nurse and technician and the story was similar to Zombrano.

In Chindu, with a population of 4,000, there was only one nurse before the arrival of the Cubans. Now the clinic is full time with a Cuban doctor, Adonis, from Santiago de Cuba. He told us he treats all the common illnesses, makes regular house calls and tries to promote health education.

Trinidad was a municipal centre and the health centre now operates 24 hours and providing emergency service to surrounding villages, labour wards and minor surgery. Rolando, 26, from Santiago de Cuba worked with a small team of Honduran doctors and nurses and there are more Cuban doctors working individually in the villages. The health centre is not a government clinic but was built and funded by the local community. The local ‘cafetaleros’, the coffee workers, never had a health service before the arrival of the Cubans. Hurricane Mitch swept away both bridges in the town and the only building that survived was the health centre. The Director of the health centre, Ana, told us that since the arrival of the Cubans, the centre was able to operate twenty four hours.

Quimistan with a population of 7143 now has a full time clinic operated by Yelina from Santiago de Cuba and two Hondurans. The story again is the same as Zombrano.

Macuelizo clinic, with a lone Cuban doctor 27 year old Juan Carlos from Havana – a similar story. Here we went on a house visit with Juan Carlos. The house was a typical ‘bahareque’ style adobe built, and the family was very poor with open sewers nearby.

Azacualpa is a poor area of 9,635 people mainly dependent on cattle and sugar, and very close to the border with Guatemala. Here, we met 25 year old Mildred from Santiago de Cuba. She told us that she visits all the surrounding towns, visits houses and has plenty of Honduran friends. Her only problem is the distance from the brigade headquarters in Santa Barbara town, several hours away by bus, but she keeps in contact by letters and e-mail.

Perhaps the most dramatic visit we made was to the Municipality of San Jose de Colinas. Here we met the mayor, Juan Ramon Duban, who told us that before the arrival of the Cuban doctors, there was only one doctor for twenty thousand people and the clinic only operated part time, three or four hours each weekday. Now they have nine doctors around the municipality, including eight Cubans. The improvement in people’s health and the saving of lives as a consequence of the Cuban doctors was visibly obvious he said. The health promotion programme was very popular. The Cubans are trying to obtain, through a Honduran NGO, X-ray, laboratory and sterilising facilities.

As if to underline what the mayor said, we visited the clinic at Colinas to find a prematurely born baby, surviving, we were told because of the presence and care of Cuban doctors. 20 years old Yanira Rivera Rivera gave birth in the village of Loma Larga 22 hours before we arrived. The baby girl was born at 34 weeks and weighed less than three pounds. Family and villagers thought she would not survive as the only facility for premature babies was hours away in San Pedro Sula or Santa Barbara, and the family had no money for the journey. So mother and baby were brought to the Cuban doctor, Juliana from Pinar del Rio, at the clinic to ‘see what she could do’. On examination, there appeared nothing very serious but the baby was unable to suckle and feeding was crucial to the baby’s survival. Juliana, the Cuban doctor, had to take milk from the mother and feed the baby with a syringe, calculating how much to give against the baby’s weight. The baby would be fed whilst being held against the mother’s body for warmth and smell in what was described as the ‘kangaroo mother’ method. The doctor then gave medication and vitamins and trained the mother how to care for the premature baby whist training a Honduran nurse in these special care techniques. As we left, mother and baby were stable and the mayor and other locals knew that this was another of the more than twenty thousand lives saved by the Cubans. The baby had not been named but it was likely she would be named after the doctor.

After leaving Santa Barbara Department we returned to Comayagua where a similar structure of Cuban doctors existed. In one brigade’s area, the infant mortality rate had been reduced from 34 per 1000 births to 10.5 and in another area it had been reduced from 32 to an astonishing 4.06, all down to Cuban intervention. We were told that an estimated 15% of the population were infected with HIV/AIDS. We were also told that the brigades had made 229,170 house visits and had recorded 1,103 lives saved including 73 children.

From Comayagua, we went to the Department and town of La Paz. There were twelve Cuban doctors in the local hospital specialising in orthopaedics, surgery, dermatology and general medicine. There were four Cuban doctors in the most inaccessible areas, where there were high levels of poverty, no electricity, dangerous mountains, and in one case, next to the border with El Salvador, where communications were easier through the El Salvador mobile phone system.

After returning to Tegucigalpa, we visited a brand new clinic at Santa Rosa a Lima in El Paraiso Department, with a range of facilities including a labour ward, dental surgery, general surgery, operating theatre, x-ray unit, gynaecological unit, microbiology laboratory and ten beds for admissions. The whole clinic was staffed completely by Cuban doctors, nurses, dentists, surgeons, and laboratory technicians. Before Hurricane Mitch, there was no health facility in this area. Now there is a flourishing new self reliant clinic serving 37,000 people directly, and 150,000 in total. There is also a thriving nursery for working single mothers and their children. The Cuban doctors also make home visits, campaign for health promotion and prevention of disease, look after single mothers in their homes, help with resources for feeding the children, and take care of their health. Twenty two of the children are infected with AIDS. The nearest hospital is sixty kilometres away. This social family project is the result of collaboration between Cuba, Honduras, the church and a Honduran NGO Sociedad Amigos de los Ninos. In a few years, newly qualified Honduran medical staff trained by Cubans will take over the facility

We visited the Faculty for Medical Science at the University in the capital Tegucigalpa. We met Cuban specialists training Honduran medical students, we spoke to the students and the Rector of the Faculty was keen to meet us. The Rector told us that in the aftermath of Hurricane Mitch, the Cuban Medical Brigade saved many lives and went on to campaign against many diseases, including lecto spirosis, dengue, malaria and cholera, and then went on to improve the environment. There were three themes to the Cuban mission – saving lives, the campaign against disease, and prevention, health promotion and education. The Honduran system had been based on curative medicine and consequently the three themes would have consequences throughout Honduras and not just in the areas where Cubans practised. He told us that previously, more than 30% of Hondurans had no access to health care. Since the arrival of the Cuban Medical Brigade, there was now full access, particularly in the poor and rural areas. The current higher levels of health care were due to the Cubans. A very important contribution from the Cubans was the development of resources and training of Hondurans to both pre and post university levels, and there were nearly seven hundred Hondurans studying in Havana who, when qualified, will return as professionals to their villages and rural areas

He explained that the medical students being trained in Honduras by the Cubans would work for one year at a minimal wage as part of their training. Those qualifying in Havana, are also contracted to work for one year in their communities, and after they would work as part of a project run jointly by the Association of Parents of Students, the Association of Students, the local community and the state on the same salary as other doctors. When asked why these newly qualified doctors would not go into private practise or to the United States where they could earn significantly more, he replied that it was a question of community loyalty and moral pressure.

He also explained that there were other joint Honduran/Cuban ongoing projects and plans. These were in the fields of university education, health, teacher training, science, chemicals and pharmacy. Various academics and university leaders were visiting Havana to develop more projects and the relationship will be prolonged. Some of these projects were with a number of ethnic groups such as the Tawahki, the Tolipa and the Garifuna, living in the north or on the Mosquito coast.

We spoke to 29 year old Evelin, a Honduran medical student being trained by Cuban teachers. She had been studying for seven years and was now studying General Medicine. She described herself as coming from a middle class family because her father was a mechanic and her mother cleaned shoes. She had three brothers and told us she had wanted to be a doctor from her childhood. She said that the Cuban teachers were very professional, were very good teachers and that the students loved them. She aspired to become a gynaecologist and she thought life would be better in the future because of the Cuban doctors

All of our experiences in Honduras suggested that both the Honduran professionals and people had the greatest respect for the Cuban doctors. In Santa Barbara, the love and respect for the Cuban doctors was displayed by ordinary Hondurans as well as Honduran doctors, environmentalists and teachers we met. Jenry’s car had been donated by a Honduran doctor in Cortes. In La Paz, we experienced a very special Saturday night Cuban social evening attended by many Hondurans and in Santa Rosa a Limo the affection for the Cubans was striking. We heard a few anecdotal examples of this respect when we were in Santa Barbara. We knew that a dangerous gang culture had developed in Honduras. We heard the gunfire from our Motel in the capital and a Honduran friend was engaged in a teaching project in local schools to combat gang culture in the countryside. We were told that in San Pedro Sula, police had imprisoned huge numbers of two rival gangs and one block housing members of one gang had burned down killing over one hundred inmates and wounding scores more. In the local hospital, Honduran doctors had declined to treat the wounded, presumably because of fear of death threats from the other gang. It was left to the Cuban doctors to treat them. In another incident in the same town, Hondurans told us that two Cuban doctors were mugged for their bags, and robbed. Honduran onlookers shouted to the muggers that the two were Cuban doctors. Apparently the muggers then returned the bags, apologised and left.

We heard similar stories in Tegucigalpa as well as a story about Cuban doctors in Venezuela. Apparently, somewhere in rural Venezuela, some Cubans were held up by Venezuelan highway robbers. It was normal for robbers to kill victims if they had nothing to hand over. The victims explained that they were Cuban doctors and had no money. The robbers then gave the Cubans some of their own money in case they were held up by other highway robbers so they could hand over the money and save their lives. Whilst such stories are anecdotal, they do confirm our experience in both Haiti and Honduras

We met Efren, the head of the Cuban Medical Brigade, before we left as we had a number of questions to ask him. We asked him to explain the projects in the north of the country as it was impossible for us to visit them because there were few roads and transportation was only by plane or river. He explained that the Cuban doctors in those areas had to travel by a motorboat to visit various communities and ethnic groups

The Garifuna people had no access to health care at all before the Cubans came. They were descendants of slaves transported to the British St Vincent Islands and expelled in 1797 after they had rebelled against the British without. They were dumped on an island off the Mosquito Coast, and developed as an isolated community in Gracias a Dios Department. We had previously met Alex, a Garifuna, at the Latin American School in Havana. Once qualified, he and his colleagues would return to their villages to take over from the Cubans building a health system there for the first time.

Efren explained the work the Cubans were doing with the Tawahka, a community of Amerindians living along the Rio Patuca. At the request of the Honduran first Lady and the leadership of the Tawahka, the Cubans began to develop a comprehensive health care programme with the purpose of protecting the population and developing the region. The Tawahka were considered by UNESCO an anthropological reserve in serious danger of extinction as a result of abrupt population reduction. Their life expectancy and infant mortality rates were very poor when the Cubans arrived, but through a combination of methods, the lives of the Tawahka improved. Before the arrival of the Cubans, their life expectancy was 40 and it is now 47, the infant mortality rate was 92 per 1,000 live births and it is now 8.7, the maternal mortality rates was 60 per 10,000 live births and it is now zero, 92% suffered from malnutrition but this has been reduced to 60%. The Cubans have set up a centre with a computer, TV and video, powered by solar panels, to teach the Tawahka methods of health promotion, combating disease and improving diet and they have built ovens for baking bread. The Cubans are working jointly with UNESCO to preserve their culture, and there has been support from NGO’s and the German government. However, the doctor’s visits and communication in general has come to a temporary halt because the engine of the motor boat is broken and this was seen as a big setback. The Cubans also need funding for flour and other ingredients for the ovens to make bread. This would contribute significantly to reducing malnutrition.

We asked Efren to identify the priority areas in which we may provide help to the brigade in Honduras. He was very emphatic that top priority was a new motor for the boat; secondly it was flour and other ingredients for the Tawahka to bake bread, and lastly, solar panels and computers for the isolated doctors to improve communication, enhance their work and to support education activities with remote communities.

It was suggested that if we wanted to see what was really possible in the field of Cuban medical collaboration, we should visit Venezuela. In November 2005, a SI group including Eddy Brown, a Cuban interpreter from the CTC (the Cuban TUC) and Rodney Bickerstaffe, former General Secretary of UNISON (Britain’s biggest union) and currently President of War on Want (an anti poverty NGO), visited Venezuela. We saw a broad range of projects including the Cuban literacy project ‘Si, se puede’ or ‘we can do it’. Collaboration between this Cuban project and the Venezuelan Government had led to UNESCO declaring Venezuela illiteracy free. This was based in the slums and shanty towns as well as the countryside.

But again, it was the advances in health attributable to the Cuban Medical Brigade that really impressed us. Out of a population of 25million, 17 million are covered by the Cuban health project ‘Barrio Adentros’. This project, again based in the poor barrios, provides free health care to the population through around 24,000 Cuban doctors and health professionals. The rest of the population are covered by an expensive private health care system. Venezuelan doctors were asked to provide health care in the poor barrios, but they refused, so an agreement was made between the Venezuelan government and Cuba in 2003. When the Cuban doctors first arrived, there was nowhere for them to set up their family doctor practises so they were based in individual poor families homes although there is a programme to build new accommodation in two roomed buildings, one for consultation and the other for living in. This was the first time the Venezuelan poor had had access to a doctor. Venezuelan doctors had been scared to enter the barrios because of security fears. This myth was dispelled by the voluntary actions of the Cuban doctors. The Cubans visited every home assessing the risks to health and establishing health prevention programmes, vaccination campaigns and establishing diagnoses. The Cuban specialists in general medicine worked as a team with the local population in the areas of health promotion, health education, promotion of sports, and participation in health committees

We visited the industrial city of Valencia in Caribobo State, where we were told there were 250 families per unit – a Cuban doctor and support including dentists, nurses and technicians. In addition there are a number of Rehabilitation Centres which provide support to the units. The main health hazards were described as rats, cockroaches and other pests, dengue fever, yellow fever, respiratory problems and parasites. The emphasis was on prevention of disease, change of lifestyle, diet and exercise. The poor suffer greatly because of the high incidence of drug problems and violence and there are programmes directed at these issues, all education programmes are free. It was emphasised to us that this is a transitional process and that they are creating a new paradigm, changing the mentality of the population. The health system would operate on the pyramid model, with most of those previously excluded from health care being treated at the base level where 80% of cases would be resolved, 15% at the second level and 5% at the apex. Also the Barrio Adentro scheme could not be seen in isolation from the other projects or ‘misiones’ including ‘plan Robinson’ a programme to eradicate illiteracy, ‘plan Ribas’ a project to develop secondary education and training for the poor, and ‘plan Sucre’ that takes education for the poor to University level. The joint Cuban Venezuelan nature of all the projects was stressed to us.

In the field of medical training, there are currently more than 2,000 poor Venezuelans receive free medical training either in Cuba or in Venezuela in addition to the thousands being trained by Venezuelan teachers of medicine. The government says that they estimate that Venezuela will need around 30,000 doctors in the future, but their plan is to train up to 100,000 doctors so they have 70,000 surplus that could replicate the internationalist role of the Cuban doctors in providing free medical care to the poor of the world.

However, training doctors and establishing a primary health care system in the barrios was only the first step. The next step was to build 600 Diagnostic Centres across the country, which would form the second level of the pyramid. The construction of these centres is being funded by PdVSA, the Venezuelan state owned oil industry. The state of the art equipment will be funded by Cuba and they will be staffed by Cuban doctors. 17 of these centres were to be in the city of Valencia. We visited one, recently built, and providing a wide range of services including X-ray, ultra sound scans, electrocardiograph, laboratory testing, specialist equipment for diagnosing dengue fever, hepatitis B and C, and a range of infections, accident and emergency services, intensive care, routine surgery, dental surgery, endoscope

Although we visited the TV station TeleSur, the Al Jezheera of South America owned by the governments of Cuba, Venezuela, Argentina and Uruguay, and also visited the Venezuelan Vice President, the most impressive project we saw was ‘Operacion Milagro’, or Operation Miracle. This is a joint Cuban Venezuelan project to restore sight to the poor of Latin America and the Caribbean. A government signing up to the project will pay the air fare of its patients to Cuba via Caracas, the capital of Venezuela. The surgery and accommodation are free

The hospital at the centre of the project in Havana is the Raymond Pando Ferrar hospital, built as a result of the raising of public funding in 1957 and completed after the revolution. It now has a section specialising in eye micro surgery, and also provides services to all specialties for eye treatments. It is the most advanced in Cuba and has become the reference centre for specialist eye treatment centres around Cuba. Since July 2004 it has been the centre of Operacion Milagro restoring sight to blind and seriously visually impaired patients from not just across Cuba but also for those patients from low income families across the whole subcontinent. In 2004 they treated 5,000 patients and in 2005, more than 30,000. In the future the hope to treat 250,000 patients a year at the hospital and at other Cuban hospitals linked to the Pando Ferrar, as well as new centres being set up by Cuba in Bolivia, Ecuador and Venezuela. Whilst we were visiting, the hospital was treating patients from Cuba, Venezuela, Honduras, Bolivia, Argentina, Surinam, St Lucia, Guyana, Dominica and St Kitts and Nevis

The conditions they are treating include cataracts, teri pterigium, stravism, occula plastia, retinopatia, glaucoma, short sightedness and the use of laser surgery, plastic surgery, neuro ophthalmology refractive surgery and cornea transplants and surgery. They can restore sight to those whose conditions have often been described as irreversible. The equipment in the hospital is state of the art from Germany and China with the spectacles coming from China.

Before we left Caracas, we learnt that Cuba was flying patients and relatives from Venezuela to Havana at the rate of 1,500 daily. Since then, they have bought a small fleet of new Russian jumbo jets to take over this transportation

Our travels took us to Cuba, Haiti, Honduras and Venezuela to see the work of the Cuban Medical Brigades. At present they operate in more than 60 countries, and they offered 1,500 doctors to go to New Orleans to help victims of hurricane Katrina – an offer refused. They also sent 2,000 to help the earthquake victims in Pakistan, and more to Indonesia. Our conclusion is that there probably is no other country but Cuba that can do this work on this scale. The lives they have saved, the sight they have restored, the infant and maternal mortality rates they have reduced really justify their slogan of ‘A better world is possible’! Whether it was the armed opposition rioters who protected us when the knew we were guests of the Cubans, the muggers in Honduras who returned the wallets to their victims after being told their victims were Cuban doctors, or the highway robbers in Venezuela who, after discovering their victims were Cuban doctors, actually gave them some money to save them from further hold ups, the affection in which the Cuban doctors are held is legend.

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