Sunday, January 16, 2011

Negotiations and Love Songs: Cuban Doctors at Home and Abroad (WSJ)

New Prize in Cold War: Cuban Doctors
The Wall Street Journal, January 15, 2011

Nearly 1,600 Cuban doctors have defected to the U.S. since 2006 under the little-known immigration program that targets Cuba's overseas medical "brigades." (The on-line version of this article at the WSJ website has some great multimedia content).

By Joel Millman (Write to Joel Millman at )

Dr. Felix Ramírez in The Gambia in 2008.

Felix Ramírez slipped into an Internet cafe in the West African nation of The Gambia, scoured the Web for contact information for U.S. diplomats, then phoned the U.S. embassy in Banjul, the capital.

He told the receptionist he was an American tourist who had lost his passport, and asked to speak to the visa section. As he waited to be connected, he practiced his script: "I am a Cuban doctor looking to go to America. When can we meet?"

Dr. Ramírez says he was told to go to a crowded Banjul supermarket and to look for a blond woman in a green dress—an American consular official. They circled one another a few times, then began to talk. That furtive meeting in September 2008 began a journey for the 37-year-old surgeon that ended in May 2009 in Miami, where he became a legal refugee with a shot at citizenship.

Dr. Ramírez is part of a wave of Cubans who have defected to the U.S. since 2006 under the little-known Cuban Medical Professional Parole immigration program, which allows Cuban doctors and some other health workers who are serving their government overseas to enter the U.S. immediately as refugees. Data released to The Wall Street Journal under the Freedom of Information Act shows that, through Dec. 16, 1,574 CMPP visas have been issued by U.S. consulates in 65 countries.

Cuba has been sending medical "brigades" to foreign countries since 1973, helping it to win friends abroad, to back "revolutionary" regimes in places like Ethiopia, Angola and Nicaragua, and perhaps most importantly, to earn hard currency. Communist Party newspaper Granma reported in June that Cuba had 37,041 doctors and other health workers in 77 countries.

Estimates of what Cuba earns from its medical teams—revenue that Cuba's central bank counts as "exports of services"—vary widely, running to as much as $8 billion a year. Many Cubans complain that the brigades have undermined Cuba's ability to maintain a high standard of health care at home.

The U.S. immigration initiative is reminiscent of the sort of gamesmanship that was common during the Cold War. It has interfered with Cuba's program by triggering defections of Cuban medical personnel all over the globe—an average of one a day since the U.S. countermeasure began in 2006. Cuba generally doesn't include doctors among the 20,000 or more Cubans it authorizes to immigrate to the U.S. each year.

State Department officials say it isn't the intention of the U.S. government to use the immigration program, known as CMPP, to engage in espionage or to disrupt medical missions. Cuban doctors, a State Department spokesman says, "are often denied exit permission by the Cuban government to come to the U.S. when they qualify under other established legal channels." One goal of CMPP is to get Cuba to change that.

CMPP was the brainchild of Cuba-born diplomat Emilio González, director of the U.S. Citizen & Immigration Services from 2006 to 2008. A former colonel in the U.S. Army, Mr. González is a staunchly anti-Castro exile. He has characterized Cuba's policy of sending doctors and other health workers abroad as "state-sponsored human trafficking." The Cuban doctors, he says, work directly for health authorities in other countries and have no say in their assignments, salaries, hours or work conditions.

Cuban doctors themselves regard such overseas assignments differently. Their salaries in Cuba top out at about $25 a month. When serving overseas, they get their Cuban salaries, plus a $50-per-month stipend—both paid to their dependents while they're abroad, according to Cuban doctors interviewed for this story. In addition, they earn overseas salaries—from $150 to $1,000 a month, depending on the mission, the doctors say.

"In Haiti they paid us $300 a month, in gourdes, the Haitian money," says one former overseas doctor who is now back in Cuba. "I converted my salary, and lived fine on $100 per month." With her savings, she says, she bought a television and laptop computer, items she couldn't have gotten in Cuba.

Ramón González, a defector who served on medical missions to Ghana and Gambia, says Cubans' entrepreneurial instincts make for almost unlimited profit opportunities. "You go to the African flea market and buy a bathing suit from the U.S., anything with a Speedo or a Nike label. It's like 45 cents in Africa," he says. "You sell it for $5 in Cuba." An even more lucrative sideline, he says: private medical practice, including abortions.

Dr. González says performing abortions can be a gold mine for Cubans, particularly in the Middle Eastern nations that pay the best salaries. "The vast majority of Cuban doctors fight to get onto a mission because they can accumulate thousands of dollars," says Dr. Darsi Ferrer Ramírez, director of the antigovernment group Juan Bruno Zayas Center of Health and Human Rights in Havana.

The 41-year-old dissident says the program is rife with corruption. "It's known that to get to the better countries—we're speaking of South Africa, Brazil—there are functionaries who will take money under the table. It costs between $500 and $1,000," he says.

Juan Bautista Palay, chief of physical therapy at Havana's 10 de Octubre Hospital, acknowledges that money is what draws colleagues abroad. "You'd go, too, if you could triple your pay," he says. He denies anyone from his facility has paid bribes to serve abroad.

The U.S. immigration program gives Cuban doctors yet another reason to serve abroad: a way to resettle in the U.S.

Ordinary Cubans seeking asylum must reach American shores before applying. Under CMPP, Cuban doctors can do so from U.S. embassies anywhere in the world. Of the nearly 1,600 defections through Dec. 16, more than 800 health workers have defected from Venezuela alone, and nearly 300 have come from Colombia and Curacao, which don't host Cuban medical brigades but are easily reached from Venezuela. Another 135 have come from four other countries: Bolivia, Guatemala, Namibia and Peru. Others have showed up to defect in such far-flung locales as Qatar, Fiji, Djibouti and Mauritius.

Dr. Ramírez's odyssey began when he was selected for a two-year posting to Gambia. Cuban doctors there are at the pinnacle of the public-health community, teaching in medical colleges and running hospitals. Dr. Ramírez says his aim from the start was to use CMPP to defect. He says he kept his plan secret from his wife and parents, who stayed behind when he left Cuba in 2008. Dr. Ramírez was assigned to run the surgery unit at the Royal Victoria Teaching Hospital in Banjul.

When he arrived in the country to join a 138-person Cuban delegation, he surrendered his passport to security personnel at Cuba's embassy. Cuban doctors also had to turn over other identification documents like driver licenses, Dr. Ramírez says, to hinder any attempt to satisfy U.S. diplomats of their bona fides as defectors. He kept his. "We had to get cellphones, too, so they always could find us," he says. Dr. Ramírez bought two cheap phones—one to talk with his bosses, the other to plot his escape.

His meeting with the U.S. consular officer at the Banjul supermarket set his plan in motion. Mr. Ramírez says he was able to persuade the officer—he says her name was Wendy Kennedy—that he was a Cuban doctor working in the country. Their next meeting was at the hospital, he says, where Ms. Kennedy conducted a formal interview to prepare his asylum request.

The State Department declined to make Ms. Kennedy available for comment, but confirmed some details of Dr. Ramírez's account, including that Ms. Kennedy worked in Gambia at the time of his asylum application. Dr. Ramírez had to wait months before learning whether he would be granted asylum. He got the news in May 2009 via cellphone. Ironically, he says, he was at an emergency meeting called by his brigade coordinator to discuss two Cubans who had just abandoned their mission and fled to neighboring Senegal.

"They called us in to warn us not to try to flee, or else our families in Cuba would be punished," he recalls.

Getting a U.S. visa was one thing, but getting out of Gambia was another thing altogether. His Cuban superiors had his passport, and trying to get out by air would likely attract the attention of Gambian authorities, who would alert the Cubans. He figured he had to get to Senegal. There was no one to trust among his fellow expatriates, he says. He felt like a prisoner in the home he shared with four other Cubans. "There's always one who is the informer," he says.

He needed permission from a brigade coordinator even to visit an African colleague's home for dinner. He had befriended a Lebanese merchant who was a patient. The merchant connected him with a smuggler, who agreed to take him to Senegal for $500. Dr. Ramírez left the night after his asylum request was approved, carrying documents from U.S. consular officials in Banjul. In Senegal, he discovered five comrades from the Gambian mission who, unbeknownst to him, also had been plotting their escape.

At the airport, he showed airline officials his U.S. entry documents and was allowed to board a flight to Spain. When he arrived, a U.S. diplomat vouched for him so he could board a flight to the U.S.
It is unclear how disruptive defections like Dr. Ramírez's are to Cuba's medical-mission program. Only a small percentage of Cuban doctors sent overseas have actually defected, making it unlikely the program has put much of a dent in revenues collected by Cuba.

Information about exactly how much Cuba makes from medical brigades is hard to come by. In many cases, Cuba extracts a direct payment either from a host government or an international aid group. Individual Cuban doctors are paid only a portion of what Cuba collects.

Since Hugo Chávez came to power in Venezuela in 1998, Cuba has been bartering doctors for Venezuelan oil. The U.S. Energy Department estimates that Venezuela ships Cuba 90,000 barrels of oil a day—worth more than $2 billion a year at current prices. In addition, Venezuela pays Cuba for medical teams sent to countries that Mr. Chávez considers part of Venezuela's "Bolivarian" sphere. Bolivia, Honduras, Ecuador and Paraguay all use Cuban doctors paid for by Venezuela. Germany, France and Japan, working through the Pan-American Health Organization, paid $400 per month for each doctor sent to work in Honduras after a hurricane in 2005, according to the Honduran government.

Cuba's Public Health Ministry said in November: "As a principle, we have prioritized donating medical brigades to countries with grave health problems and few resources and hard-to-reach settlements, where local doctors refuse to work." It said that Cuba intends to send more doctors abroad, to nations better prepared to pay for services. "In countries whose economy permits, we will increase the presence of our professionals, with compensation," it said.

Julie Feinsilver, who tracks Cuba's medical diplomacy as a senior fellow of the Council on Hemispheric Affairs in Washington, a think tank, says such arrangements benefit both Cuba and the host countries. "Do you think that it is possible to hire doctors for less than $1,000 a month? The Cuban government does earn money, albeit considerably less than others would for similar services."

By summer's end, Dr. Ramírez and the five other Cubans who defected with him from Gambia were all in Miami. Four of them work as instructors at Dade Medical College. Dr. Ramírez is a surgical assistant at Baptist Health South Florida's hospital in Homestead, Fla.

Dr. Ramírez's parents and wife—and a son born shortly after he left for Africa, whom he has never seen—remain in Cuba, in Camagüey. All of them are eligible for U.S. visas under the CMPP program, but there is virtually no chance they'll get out soon. Dr. Ramírez says his wife lost her job at a hospital because of his defection. "They're blacklisted for five years, minimum," Dr. Ramírez says. "I'm a traitor to the homeland now."

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