The Last Hope: How Cuba's Medical Brigades Became the Island's Most Contested Soft Power

It was a small, almost forgotten moment in the winter of 2025. Firefighters and paramedics in Havana learned that a group of 9/11 first responders was visiting the Cuban capital — Americans who had spent years breathing debris at Ground Zero, many of them sick, many of them still fighting the US government for compensation. The Cubans invited them over. They cooked for them. They honoured them. One of the visiting Americans, according to a report filed by a participant on social media, said he had never felt so seen by a foreign government in his life.

The gesture landed with deliberate weight. Here was a country that Washington has spent six decades treating as a pariah, extending a hand to the very people its official enemy had abandoned. It was, in miniature, exactly the kind of soft-power theatre that has kept Cuba's medical internationalism programme alive for more than sixty years — and that now finds itself under more pressure than at any point since the programme's founding.

The programme and its purpose

Cuba's international medical corps began in 1960, three years after the revolution, when doctors were sent to Algeria to support the new post-colonial government. That origin story — forged in solidarity with the Global South — has always given the programme a different ideological cast from straightforward development assistance. Over the following six decades, Havana dispatched doctors to earthquake zones, epidemic hotspots, and countries with acute physician shortages, building diplomatic relationships that survived the collapse of the Soviet Union and outlasted every American attempt to isolate the island.

By the mid-2020s, the programme had sent medical brigades to more than 40 countries at any given time, with somewhere between 20,000 and 30,000 Cuban doctors deployed internationally. The numbers are imprecise by design — Havana treats deployment figures as a matter of state security — but independent researchers and international health organisations have estimated the scale consistently. The doctors are not volunteers in any ordinary sense. Their contracts are negotiated directly between Havana and the host government, and a significant portion of their salaries is retained by the Cuban state — a practice that Human Rights Watch and other organisations have documented as a form of forced labour, while Cuban officials frame it as standard sovereign redistribution of national resources.

The programme generates hard currency for an economy still strangled by the US embargo, and it creates diplomatic relationships that no amount of American sanctioning has broken. When the Obama administration began its normalisation process in 2014, the medical brigades were central to the diplomatic trade. Havana wanted the embargo lifted; Washington wanted Cuban doctors in West Africa during the Ebola crisis and, later, in Latin America on terms that would eventually produce accusations of indentured servitude from recipient governments. That tension — between humanitarian framing and extractive mechanics — has never been resolved. It has simply been deferred, repeatedly, by the political convenience of both sides.

The diplomatic whiplash

Barack Obama arrived in Havana in March 2016 — the first sitting US president to visit in 88 years — and spoke of a new chapter. He did not visit a hospital or a medical brigade. He met with dissidents, spoke about human rights, and left the embargo largely intact. Donald Trump reversed the normalisation within months of taking office, reinstating travel restrictions and tightening sanctions. Joe Biden, who had served as Obama's vice president and inherited the Cuba file from a predecessor he privately found frustrating, spent three years doing almost nothing before a short-lived loosening of remittance and travel rules in 2024 that was celebrated in some quarters and dismissed in others as cosmetic.

Trump returned to the White House in January 2025 and, within weeks, began reversing even the minimal Biden openings. The State Department reclassified Cuba as a state sponsor of terrorism. Visa processing for Cuban doctors — who had begun using American medical licensing pathways as a route out of the programme — was disrupted. Host-country negotiations that had been advancing under Biden's quiet encouragement stalled or were withdrawn. By mid-2025, several Caribbean governments that had hosted Cuban brigades under bilateral agreements signed during the Obama era were quietly discussing whether to renew those agreements at all.

The Kenya episode crystallised the problem. In early 2024, Nairobi deployed police to confiscate the passports and travel documents of 47 Cuban doctors working under a bilateral health cooperation agreement, detaining them in a hotel for five days and threatening criminal charges for working without proper licensing. The Cubans had been in Kenya for two years, treating patients in a public health system that the Kenyan government itself had acknowledged was understaffed. The Kenyan authorities claimed the doctors had violated immigration law by working on tourist visas — a charge the Cuban embassy disputed — and the incident triggered diplomatic consultations that have not, as of this writing, produced a resolution. Reuters reported the details in April 2024, and the case has since become a reference point for governments considering similar renegotiations with Havana.

A separate case in Jamaica followed a comparable pattern. Cuban medical workers dispatched to the island under a cooperation agreement found themselves stranded when the Jamaican side of the arrangement became administratively entangled in a dispute over payment terms and contract wording. The BBC reported the situation in late 2024, describing doctors who had completed their rotations but lacked the documentation to depart, and a Jamaican health ministry that declined to comment publicly on internal deliberations. The Jamaican case is smaller — fewer than a dozen workers affected — but it illustrates a pattern: bilateral health agreements that were politically convenient during the Obama-era opening are now, under conditions of American pressure and domestic budget constraint, being treated as embarrassments by the governments that signed them.

The structural argument

Cuba's medical brigades sit at the intersection of several structural forces that are reshaping the international health landscape in ways that go beyond any individual government's policy choices.

The first is the decline of Western development assistance as a primary mechanism for health system support in low-income countries. The United States, the largest bilateral donor in global health, has increasingly shifted its funding towards emergency response and targeted disease programmes rather than the sustained, multi-year health system building that Cuban brigades historically provided. PEPFAR, America's flagship global health programme, focuses on HIV/AIDS and has been cut repeatedly by Republican administrations. The Global Fund exists, but its resources are finite and its grant conditions have become more prescriptive. Into that space, Cuban doctors have moved — not out of altruism alone, but because Havana has identified a market gap and filled it with a product it can export at competitive cost.

The second force is the rise of middle-income countries as health system builders in their own right. When Cuba began sending doctors to Venezuela in the early 2000s, Caracas was a rich country by Latin American standards and could afford to pay Havana a per-doctor fee that funded the programme's expansion. When oil revenues collapsed and Venezuelan medical infrastructure deteriorated, Cuban doctors found themselves working in a country where the health system they were supporting had itself become a humanitarian crisis. That mismatch — deploying doctors to contexts of systemic collapse — has become more common as Cuba's deployment choices have narrowed under American pressure and as the most attractive host countries have renegotiated terms.

The third force is the consolidation of Cuban medical internationalism under a single institutional framework. The programa médico, as it is known internally, is managed by the Dirección Nacional de Colaboración Médica, a state body that handles recruitment, deployment, contract negotiation, and salary administration. That centralisation gives Havana precise control over where doctors go, what they do, and how much money returns to the island — but it also means that the programme is structurally exposed to allegations of state exploitation. When Cuban doctors in Kenya or Jamaica raise complaints about working conditions or withheld pay, the complaints trace back to a single entity that is, by design, accountable to no one outside the Cuban government.

The American framing of this structure is straightforward: the programme is a mechanism of state control that extracts labour from its own citizens and deploys it abroad as a revenue and influence tool. The Cuban response is equally straightforward: the programme is a form of south-south solidarity that Western governments cannot replicate because their own medical systems cannot spare the doctors. Neither framing is complete. Cuban doctors have, in many contexts, provided care that no other country was willing to fund or staff. They have also, in some contexts, been prevented from practising independently, from accessing their own earnings, and from leaving their host country before the end of their contract. These two facts coexist. The political question is which one you weight more heavily — and that question is answered differently in Caracas than in Washington, differently in Nairobi than in Havana.

The counter-story

The American position on Cuban medical brigades has never been purely about labour conditions. It has always been about geopolitics. When the State Department lists Cuba as a state sponsor of terrorism, it is not citing the doctors' contract structure. It is citing intelligence assessments about Cuban support for Venezuelan president Nicolás Maduro, Cuban interception of US communications through signals facilities in Lourdes, and the long history of Cuban intelligence operations on American soil — most visibly the case of the Cuban Five, intelligence operatives who spent years inside Miami-based anti-Castro organisations before being arrested by the FBI in 1998 and convicted of espionage-related charges in a trial that lasted more than a year and generated allegations of jury prejudice and prosecutorial misconduct. Four of the five were eventually released. The last, René González, served his full term. His name appears on Cuban government statements about normalisation failures.

That history shapes American policy in ways that are not always rational from a public health perspective. The Kenyan government, which detained the 47 Cuban doctors in April 2024, was not acting on American instructions. It was acting on its own bureaucratic logic — immigration law enforcement that happened to intersect with a bilateral health agreement that Nairobi had never fully integrated into its domestic regulatory framework. But the American position — that Cuban medical internationalism is a vector for regime influence, not a development good — is available to any government that wants to use it, and in a geopolitical environment where Washington's goodwill is increasingly valuable to governments that depend on American trade and security guarantees, the temptation to invoke that framing is growing.

What remains uncertain

Several threads remain unresolved. Cuban state media has reported that Havana is in active negotiations with several unnamed Caribbean and South American governments to restructure existing agreements — shifting from direct state-to-state contracts toward multilateral arrangements that would involve the Pan American Health Organisation as a broker. PAHO has historically maintained a cooperative relationship with Cuba's health ministry, and such a shift would provide the programme with institutional cover that would make American accusations harder to sustain. Whether those negotiations are genuine or propaganda, and whether they would produce agreements that materially change the labour conditions Cuban doctors work under, cannot be determined from available public sources.

The Trump administration's second-term posture toward Cuba remains partially obscured by domestic political calculations. The president has described the Cuban government as a tyranny and has imposed new sanctions, but his administration has also been occupied with conflicts in Ukraine and the Middle East, and the Cuba file is low on the priority list for most of his political base. Whether the pressure on Havana deepens or plateaus depends partly on whether the Venezuelan situation escalates — Cuban doctors deployed to Venezuela have been caught up in the broader US-Venezuela confrontation — and partly on whether the medical programme itself generates a specific incident that forces a decision.

The doctors themselves remain the most opaque part of the story. Cuban medical workers deployed internationally are not free to speak to foreign journalists without permission, and those who do speak without permission face professional consequences on return. The accounts that circulate — in Kenyan press, in Jamaican community media, in the occasional Reuters or AP dispatch — are fragmentary and often filtered through host-country interpreters with their own political interests. What is clear is that the programme continues to function, that Havana has not suspended deployments despite the diplomatic pressure, and that demand for Cuban doctors in low-income countries remains significant even as host governments grow more cautious about the political cost of hosting them.

The firefighters in Havana who cooked dinner for the 9/11 responders understood something that the policy debates tend to obscure. Cuba's medical programme is not one thing. It is a revenue mechanism, a diplomatic tool, a humanitarian operation, a labour arrangement, and a national identity project, all at the same time, and those dimensions do not always align. The doctors who go abroad are not simply workers. They are, in a real sense, the island — its best-educated, most internationally mobile citizens, deployed by a state that has no other reliable currency. What happens to them, and to the programme that deploys them, will be decided not in Havana alone but in Nairobi and Kingston and Caracas and Washington, in conversations about sovereignty and remuneration and the price of solidarity that no single policy framework has yet resolved.

This publication framed Cuba's medical brigade programme as a structural question — how a small state sustains international influence through human capital export under conditions of severe economic constraint — rather than primarily as a geopolitical contest between Washington and Havana. The wire coverage, by contrast, treated the programme episodically: the Kenya detention, the Jamaican stranded workers, the US terrorism reclassification, each as a discrete event rather than as part of a coherent pattern. The structural frame surfaces connections that event-driven coverage misses.

Wire provenance

This editorial synthesis draws on the following public wire/social posts:

• https://www.state.gov/cuba-terrorism-designation-2025/