Overview. A federal lawsuit by Cuban doctors in 2018 who were forced to work in Brazil in the “Mais Medicos” program revealed startling details about the character of Cuba’s overseas medical missions as human trafficking. Even more shocking is that the defendant in the case, who facilitated and profited from the scheme, is the Pan American Health Organization (PAHO), a U.S.-based and taxpayer supported organization. Though the State Department has labeled Cuba’s medical missions as human trafficking and verbally criticized PAHO’s participation in Mais Medicos, PAHO has arrogantly defied U.S. law and policy. It has spent millions of dollars to exploit its statutory immunity to avoid accountability in the lawsuit, and resisted past administrations’ efforts to hold it accountable. The most direct and effective way to hold PAHO accountable, and send a clear message to all foreign governments that Cuba’s medical missions violate international human rights law, is for the President to issue an executive order revoking PAHO’s statutory immunity for its conduct relating to Mais Medicos.
Background. Cuba generates close to $7 billion every year from “medical missions,” in which the government “exports” doctors and other health care workers to foreign countries. Although Cuba touts these programs as “humanitarian,” the U.S. State Department has labeled them as forced labor in its 2017-2024 Trafficking in Persons (TIP) Reports, and other organizations agree. Over fifty countries currently employ Cuban doctors under this system. These revenues comprise over half of Cuba’s national budget, and are three times the amount generated by tourism. Trafficking revenue not only supports Cuba’s internal repression, but its destabilizing behavior in the hemisphere and around the world.
In Brazil, the Cuban medical mission, called “Mais Médicos,” was planned, administered, and enforced by the Pan American Health Organization (PAHO). Between 2013 and 2018, Brazil paid PAHO $2.58 billion for the labor of more than 10,000 Cuban medical professionals. PAHO sent at least $2.3 billion to Havana and kept 5% of the total — at least $129 million — for itself. The doctors received less than 10% of the total amount Brazil paid for their services.
Cuban doctors who were trafficked in Brazil, who now reside legally in the U.S. (under the DHS Medical Personnel Parole Program that President Obama ended in 2017), filed a federal class action lawsuit under the U.S. Trafficking Victims Protection Act (TVPA). The doctors had no choice about going to Brazil; their documents were confiscated and movements were limited in Brazil; they were required to indoctrinate the local population; their family members were held hostage in Cuba; they were surveilled 24-7 by Cuban intelligence operatives employed by PAHO; and Cuba and PAHO confiscated 80-90% of the sum Brazil paid for their services.
The U.S. District Court for the District of Columbia and District of Columbia Court of Appeals have both held that the doctors’ allegations that PAHO received tens of millions of dollars for moving of money between Brazil and Cuba states a violation of the TVPA. PAHO has not refuted the basic outlines of the program, but argues that it has legal immunity because the money never entered the United States. Yet, PAHO has refused to produce records, despite orders to do so by the district court, that would show the flow of money to and from the program, including the $129 million it collected. Instead, it filed an unprecedented appeal of the court’s discovery order, which is pending.
PAHO, based in Washington, D.C., is part of the UN system and the OAS, and receives tens of millions of dollars in U.S. taxpayer funding every year. PAHO’s stonewalling strategy and tactics to prevent full disclosure of its conduct, and deny justice for the doctors whose wages were confiscated by PAHO, is an insult to U.S. and international human rights law.
Members of Congress of both parties have demanded that PAHO be held accountable for its actions, and compensate the doctors in accordance with the TVPA. In 2019-2020, the Trump Administration had threatened to withhold funding if PAHO did not account for its conduct in Mais Médicos, but accepted PAHO’s promise to authorize an “independent review,” including an accounting of its $129 million windfall in the interim. PAHO hired a Washington D.C. law firm to perform such a review, but it has refused to release the firm’s report. PAHO has thus failed to deliver on its promise to the Trump Administration.
Action to be taken. PAHO’s immunity defense arises from the International Organization Immunity Act, 22 U.S.C. §288 (“IOIA”), and President Eisenhower’s 1960 Executive Order 10864 (1960 WL 66346 (Pres.) conferring upon PAHO international organization status. However, the IOIA makes it clear that any President has complete discretion to withdraw, modify, or revoke an organization’s immunity:
The President shall be authorized, in the light of the functions performed by any such international organization, by appropriate Executive order to withhold or withdraw from any such organization or its officers or employees any of the privileges, exemptions, and immunities provided for in this subchapter(including the amendments made by this subchapter) or to condition or limit the enjoyment by any such organization or its officers or employees of any such privilege, exemption, or immunity. The President shall be authorized, if in his judgment such action should be justified by reason of the abuse by an international organization or its officers and employees of the privileges, exemptions, and immunities provided in this subchapter or for any other reason, at any time to revoke the designation of any international organization under this section, whereupon the international organization in question shall cease to be classified as an international organization for the purposes of this subchapter.
22 U.S.C. §288.
While the law authorizes the President to completely revoke PAHO’s immunity, no one is recommending full revocation at this time. To be sure, the doctors’ lawsuit has uncovered PAHO’s illegal participation in human trafficking, as well as other corrupt practices such as falsifying public health data to inflate the true impact of Cuba’s medical export programs. At the same time, there are people and programs within PAHO that provide important public health services in this hemisphere. Therefore, the doctors and their supporters are recommending that the President issue an executive order revoking PAHO’s immunity limited to actions arising from or related to the Mais Médicos program.
Conclusion. Presidential revocation of PAHO’s immunity for Mais Médicos-related actions is long overdue. If the doctors can win or successfully settle the lawsuit, the impact would be monumental, providing justice for the doctors who were abused by PAHO, and establishing as a matter of U.S. and international law that Cuba’s medical missions constitute human trafficking. It would put foreign governments on notice that they are violating international law if they employ Cuba’s medical professionals under the regime’s current framework. When those countries start to withdraw, or decide to pay the doctors 100% of their earned fees, it would likely dry up Cuba’s largest source of hard currency for its repressive regime.