Cuban doctors and soldiers served secretly in revolutionary Africa in the 1960s, pursuing Che’s strategy of “Two, Three, Many Vietnams.”
“The behavior of doctors toward civilians was as important for diplomatic relationships as troop discipline was for military advances.”
[The first part 1 of this article addressed the need for Cuba's participation in conflicts in Zaire, the Congo and Guinea-Bissau during the 1960s to remain concealed for over three decades. It covered the background to the struggles, what Cubans found in Africa, the role of race relations in Cuba's campaigns, and the recruitment of doctors. This Part 2 explores the working conditions of revolutionary military doctors, physical and emotional consequences on participating physicians, interactions with African civilians, Cuba's first large medical scholarship program, the first mass vaccination effort in Africa, and how Cuba's military and medical efforts affected Africa.]
Military Doctors at Work
Physicians found working conditions to be quite different from Cuban polyclinics. It was very clear to Virgilio Camacho that “although I was a doctor, I was armed because at any moment I might have to participate in combat.”  The Cuban doctors practiced in small groups. In the Congo, the group of Rodrigo Álvarez included a surgeon, an orthopedic, and two pediatricians. Later, they were joined by an anesthesiologist nurse and dentists.  In 1966, Domingo Díaz traveled toward Guinea-Bissau as 1 of 9 physicians. Once there, he was assigned to Saará in the northern region where they were “the only three doctors and there were no Cuban nurses.” They worked closely with several young Guineans and trained them as nurses. 
Since the Cuban staff rotated and PAIGC policy was to understate the extent of their involvement, some writers are not aware of the more than 40 Cuban doctors who served in Guinea-Bissau between 1966 and 1974 as historian Piero Gleijeses carefully documents. 
The physicians were forced to minimize their use of modest resources. When Amado Alfonso Delgado reached his assigned eastern front in Guinea-Bissau he found the hospital grounds consisted of “four huts: one for the wounded; one was a kitchen; one for supplies; and one, a little further away, for the doctor.” 
Juan Antonio Sánchez “was in Tanzania for a military mission from 1969 to 1970. I was a medical internist at Pemba Island. Cuba had permission from Tanzanian government as long as their presence was secret. There were no Cuban troops, only three doctors.” Their “operating room had been a garage.” 
“Cuba had permission from Tanzanian government as long as their presence was secret.”
The priority for Cuban doctors was always the health of combatants. They were treated for bullet wounds, fractures and health issues such as hernias and tropical diseases. There were many surgeries including the one in which Héctor Vera participated: “Four men who had been injured by a grenade arrived. The one who was seriously injured was operated on at night and survived. We put him on a table; Che held a lantern; Oliva gave him anesthesia; Tabito operated; Lagomasino worked as an assistant; and I observed.” 
Virgilio Camacho was in the southern front of Guinea-Bissau where the Portuguese frequently ambushed civilians who helped supply the military. Several Cubans died or were injured in these attacks.  Amado Alfonso Delgado illustrates the difficulties of surgery during combat:
“We operated whenever there were battles. Small reconnaissance planes passed overhead frequently, and when they returned multiple times we moved the camp because an attack was almost certain to follow. The hospital was burned four times. Every time a plane flew overhead two times they attacked us ... We were between two rivers. Planes and boats kept coming by and destroyed almost all the canoes we could use to flee … Most of the time we operated in places where we could set up a tiny hospital. They brought us people who had stepped on a mine or were wounded in an ambush. Almost always the wounded arrived at night and we had to operate by the light of bundles of grass. I did about 50 operations like this including several amputations. We cut dry grass, folded it over, and tied it with straw, and used it as a candle. Sometimes we couldn’t see what we were operating on, even with 8 or 10 wicks like this.” 
Other than Military Medicine
Cubans felt obligated to treat civilians injured in attacks which meant that there was an overlap between military and non-military medicine. Amado Alfonso Delgado became acutely aware that a lack of specialists had its costs. He describes an event in Guinea-Bissau,
“…a bomb fell very close to a woman and injured her in the abdomen. Since I didn’t have my assistant with me, I had to read from a booklet to find out how to apply anesthesia. I had to open her abdomen to see if she had peritonitis. I gave her a local anesthetic, and just as I was about to give the general, a plane dropped a bomb very close to us. The woman jumped up with her wound half open and ran away. I never saw her again. Later I learned that she had been found dead four kilometers from the tiny hospital.” 
Domingo Díaz had a more positive experience in the northern front:
"One day in Saará they brought us a boy about four years old named Kumba who had a large wound in his left leg. His good spirit impressed us; he didn’t have a tear or expression of pain. A few hours before the Portuguese attacked a nearby village that had no combatants and no protection. Luckily, they were able to bring this little boy to our small rural hospital. We cleaned the very dirty wound and partially sutured it because we didn’t want future complications such as gangrene. During all the treatment without anesthesia, Kumba continued as before, without a tear or expression of pain.” 
“Anyone who is undisciplined will have to be counseled or sent back to Cuba.”
Cuban officials knew that the behavior of doctors toward civilians was as important for diplomatic relationships as troop discipline was for military advances. When Cuban physicians first went to Algeria in 1963, Raúl Castro issued a strict code of conduct that included a prohibition of alcohol and intimate relations with women, and demanded absolute respect for Algerian traditions. Che spoke to physicians in Zaire of the moral aspect of their mission: “I don’t want any scandal. Anyone who is undisciplined will have to be counseled or sent back to Cuba.” A couple of years later, the Cuban command in Guinea-Bissau replaced a doctor accused of not showing respect for local customs. 
The importance of this respect grew as contact between Cubans and Africans became closer. Unlike Catholic and Protestant missionary doctors who stayed at fixed locations and required Africans to come to them, Cubans went on long walks to isolated villages to provide care. As Zaireans learned of the arrival of Cuban doctors, “peasants from the surrounding area flocked in.” Before the Cubans arrived, only nine doctors had provided care for 850,000 Congolese. Hugo Spadafora, a Panamanian who was the only foreign doctor with the PAIGC, wrote that when the Cuban physicians arrived with medicine and equipment, “the quality of the hospital’s care increase exponentially.” 
The guidelines laid out by Raúl and Che served Cuban efforts well. While their military allies in Zaire were often accused of mistreating local people, there were “no reports of the Cubans perpetrating any crimes or acts of violence against the population.” 
Instead, the Cubans won people's trust by doing countless simple procedures. These included tooth extractions, operations for hernias and cataracts, and treatments for high fever, diarrhea, confusion and stomach and shoulder pain. In Tanzania, Justo Piñero recalled that “most patients were civilian and a few were military. The most frequent problems were malnutrition, malaria, pneumonia and parasites.” 
“Before the Cubans arrived, only nine doctors had provided care for 850,000 Congolese.”
Amado Alfonso Delgado learned to treat parasitic diseases he had never seen in Cuba:
“I saw whole villages with trachoma, an infection of the eyes and eyelids that leaves people blind. I visited villages where almost everyone was blind. I saw people with advanced leprosy without fingers. There was a sickness, miasis, produced by a fly bite that causes an abscess from which worms grow. Another produces boils on the body, called oncocerciasis, that is a type of filaria. This disease has a special treatment. There is a worm that gets under the skin and the Guineans use a little stick to which they fasten a palm thread and put it in the boil and roll it around until they pull out an enormous worm called ‘the worm of Guinea.' There are many parasites and harmful insects such as the jigger flea (nigua), that gets under people’s skin in dry weather and causes a boil. You have to extract the parasite, which looks like a tick.” 
Perhaps the most unexpected tragedy was a Cuban soldier dying from eating a strawberry. They had no idea of how acidic the fruit could be and he had a perforated ulcer. “By the time he reached me” Domingo Díaz remembers, “he was in agony. We did all we could to stop the bleeding, and since we didn’t have surgical instruments, we tried to move him to the small hospital in Boké. But he died on the road.” 
Though the Cubans tried to attend to civilian medical needs, operations had to be authorized by the PAIGC zone director due to shortage of materials. This required creative searches for alternative materials, such as using coconut water (which is sterile) in intravenous fluids. On multiple occasions, Dr. Camacho “had to suture patients with domestic sewing thread,” which led to deal-making with local thread vendors. 
Truly International Medicine
The riches of Africa were being drained out as its people lay crippled or dying from totally curable diseases which did not peak the interest of wealthy Western investors. This was the case with polio. When Rodrigo Álvarez arrived in the Congo, he saw that
“Many suffered from polio. I visited an asylum attended by a single nun which was full of children with this disease. The children were crawling across the floor in very bare surroundings. The nun didn’t have supplies or staff to deal with them. I operated on dozens of these children ... The French had left nothing of the infrastructure; there were no lawyers or engineers; and only two native doctors.” 
Rodolfo Puente was the manager and one of the principle advocates for a polio vaccination campaign. He ran into two Soviet medical staff who were vaccinating as one of their duties. He asked for 5000 doses, which they happily gave him, and made arrangements with the mayor to vaccinate students. Realizing the seriousness of the situation and knowing that Cuba had recently conducted its own polio vaccination campaign, Dr. Puente called MINSAP in Havana for permission to take on a similar endeavor. MINSAP director Machado approved and assigned Dr. Helenio Ferrer, Cuba's Director of Epidemiology, to fly to Moscow for the vaccines. The Soviets agreed to provide 200,000 doses to the Congo for about $4000. Following appeals by the Cubans, they agreed to donate the vaccines, which arrived in June 1966. 
“The French had left nothing of the infrastructure.”
There were too few doctors and nurses to administer the vaccines; but, since they were in a caramel, it was possible to train others to distribute them. In cooperation with the Congolese government, its militia, the Federation of Women, and Cuban troops, Dr. Ferrer coordinated the vaccination of over 61,000 children in the first such campaign in Africa. 
However, the attempted coup of June 27 blocked administration of the second dose. Since accounts tend to be vague regarding whether this would prevent the first dose from being effective, I asked that question directly to Dr. Justo Piñero, who was in the Congo from September 1966 to November 1967. He explained that, “as a result of not getting the second dose, there would be the same rate of polio.” He returned to the Congo in May 1969 and witnessed the Congolese Ministry of Public Health administering both doses, which were provided by the Soviets. He strongly believed that the earlier joint experience with the Cubans was critical in making the 1969 effort successful. 
“Many students were selected according to personal connections or bribes.”
In Guinea-Bissau, Domingo Díaz' group found themselves with no Cuban nurses, so they trained several local youth. They were so impressed with the work of the Guineans that they obtained permission from Cabral to bring four back to attend Cuban nursing school, from which they graduated. 
A much larger venture happened earlier in the Congo when Cuban doctors noticed dedicated young people studying at night under street lights. They asked the Congolese government about sending some of them to Cuba to study. It agreed, and, on January 24, 1966, 254 youth boarded a ship for Havana. This was the first time a significant number of foreign scholarship students went to Cuba. Nevertheless, there were problems. Rather than choosing students strictly on the basis of academic performance, many were selected according to personal connections or bribes. By late 1967 more than 100 had returned home, at the request of themselves or Cuba. Despite this, by 1978, 25 had Cuban medical degrees and others graduated as lab technicians or engineers. 
Cuban authorities soon decided that its military forces would leave Africa. Yet medical personnel would continue with replacement teams of “pediatricians, orthopedics, surgeons, and ear-nose-throat specialists who would be civilians rather than military doctors.” 
Physicians, Heal Each Other
Cuban doctors provided preventive care and treatment not only to troops and civilians but also to themselves. The most famous example was Che. With him in Zaire, Rafaél Zerquera remembered the day Che's malaria was complicated by an asthma attack. Zerquera worried “How can I tell Fidel that I let Che die here?” Che was not an exception. Amado Alfonso Delgado, for example, treated himself three times for malaria. 
Virgilio Camacho spoke about how, soon after his arrival, acute jaundice caused another doctor, Jesús Pérez, to return to Cuba, leaving him with only one other doctor at their medical post. A year later he was transferred to head the military hospital in Guinea-Bissau's southern front because a doctor there was ill. 
The long walks and physical exhaustion of battlefield medicine took their toll. When Domingo Díaz arrived in Guinea-Bissau he weighed 180 pounds. He left 20 months later weighing 100 pounds. He had experienced the unusual danger of disappearing shoes.
“I returned to the base after it was completely destroyed, and I could not find any of my belongings, not even my tennis shoes. This type of footwear was the best in the circumstances, since we had to cross many rivers, and they dried out much more rapidly than boots and were a lot lighter … during the first long walks, I lost all of my toenails...my feet were constantly wet and the hiking was forever...and in Cuba I had the habit of walking five kilometers every day.” 
“Domingo Díaz left Africa weighing 100 pounds.”
Some of their most unpleasant surprises awaited doctors upon completion of their African assignment. Amado Alfonso Delgado recounted
“The year that we returned almost all of us tested positive for filaria in the blood. In the subtype Loa loa, it goes from vital organs to the eyes, leaving the person blind. This was precisely the type we had. Reading about it scared me a bit because it was said at that time, that there was not a guaranteed cure. We were treated in a hospital for two months.” 
Virgilio Camacho was also more than a little nervous:
“I had filaria, which doesn’t exist in Cuba, and I had no idea until passing through the check point. It required a double treatment: both for the adult and larva of the parasite. They didn’t have the medicine in Conakry and had to look elsewhere. Finally, I had both the intravenous injections and pills...We arrived in Cuba in January 1968.” 
Impact, Reflection, Unanswered
By the end of the 1960s, when the Cuban revolutionary government had been in power for only 10 years, doctors had been through four different scenarios in Africa:
1. In Algeria, they treated only civilians.
2. In Zaire, the rebels showed little enthusiasm for victory.
3. In the Congo, the militancy of the government proved to be empty rhetoric.
4. In Guinea-Bissau, there was a successful military uprising with a strong commander and dedicated troops.
Cuba knew that US could invade at any time. As a result of African expeditions and experience gained by military doctors, a new generation of physicians would be trained by those who had been through war and could teach others how to treat combat victims.
Perhaps the most lamentable irony of Cuba's forays into Africa was that its most capable leader, Che Guevara, led guerrillas into the least promising front, Zaire. Since no Cuban leader had been to sub-Saharan Africa for more than one day, the strategy of going to Zaire was based on misinformation, solidarity with Cuba's own black population, and the defense of its revolution. When Che ventured into his last battleground of Bolivia the following year, it was because he and Fidel agreed that Latin America must again occupy the foreground of Cuba's participation in armed struggles. 
There had been very little connection between upheavals in the approach to medicine practiced on the island and what its doctors did overseas.  Experiences of the polio campaign in Cuba was adopted in the campaign in the Congo. The exposure to medical problems in Africa was invaluable for developing Cuban understanding of tropical and infectious diseases. Nevertheless, nothing like Cuban polyclinics appeared in the battle conditions of Africa, where the necessity to provide emergency care was all-encompassing.
“’Many of our comrades are alive today only because of the Cuban medical assistance,’ noted PAIGC official Francisco Pereira.”
Cuban engagements in Africa left profound impacts, both on the host countries and on the Cubans who went. Cuba learned that if students were to travel to the island for education, they must be screened for academic potential. The Congo became prepared to complete its own vaccination campaign. Guinea-Bissau recognized its debt to Cubans for its successful struggle for independence. “Many of our comrades are alive today only because of the Cuban medical assistance,” noted PAIGC official Francisco Pereira. “The Cuban doctors really performed a miracle. I am eternally grateful to them: not only did they save lives, but they put their own lives at risk. They were truly selfless.” 
White doctors who experienced the stressful conditions and parasitic diseases of Africa witnessed even greater sacrifice by black troops. One reason that so many volunteered to serve in Africa was a feeling of urgency to spread the revolution. Later, Olvaldo Cárdenas told Piero Gleijeses that
“… we believed that at any moment they [the US] were going to strike us … and for us it was better to wage war abroad than in our own country. This was the strategy of 'Two or Three Vietnams;' that is, distracting and dividing the enemy’s forces. I never imagined then that I would be sitting here [in a living room in Havana] talking about it now—we all assumed that we were going to die young.” 
When the volunteers returned to Cuba, they did not march in parades or receive any type of public praise. There were no medals, decorations or material rewards. Bound to secrecy, decades passed before they could share their stories.  Yet the insights obtained by what they endured were essential for designing Cuban strategy, which is why Fidel grilled so many upon their quiet homecomings.
Before 1959, dedication to revolutionary medicine was expressed by students and doctors demanding full treatment for Cubans in poor urban and rural areas. This became the foundation for doctors volunteering for international missions during the 1960s. With the dawning of the 1970s, the question remained: Would sacrifices by the first doctors going to Africa come to fruition by medical staff playing a key role in toppling a major racist government on that continent?
Don Fitz is on the Editorial Board of Green Social Thoughtand is editor for the newsletter of the Green Party of St. Louis. He had been the candidate of the Missouri Green Party for Governor (2016) and for State Auditor (2018) and can be contacted at [email protected]
A version of this article with full citations appeared the November 2018 print and online issue of Monthly Reviewand in Green Social Thought. The author thanks Rebecca Fitz for interview translation and John Kirk, Linda M. Whiteford and Steve Brouwer for their helpful comments on an earlier draft of the article.
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