Yansnier Arias knew it was wrong. It violated the Constitution, not to mention the oath he took as a doctor in Cuba.
He had been sent to Venezuela by the Cuban government, one of thousands of doctors deployed to shore up ties between the two allies and alleviate Venezuela’s collapsing medical system.
But with President Nicolás Maduro’s re-election on the line, not everyone was allowed to be treated, Dr. Arias said.
A 65-year-old patient with heart failure entered his clinic — and urgently needed oxygen, he said. The tanks sat in another room at the ready, he recalled.
But he said his Cuban and Venezuelan superiors told him to use the oxygen as a political weapon instead: Not for medical emergencies that day, but to be doled out closer to the election, part of a national strategy to compel patients to vote for the government.
May 20, 2018, was nearing, he said, and the message was clear: Mr. Maduro needed to win, at any cost.
“There was oxygen, but they didn’t let me use it,” said Dr. Arias, who defected from the Cuban government’s medical program late last year and now lives in Chile. “We had to leave it for the election.”
To maintain their hold over Venezuela, Mr. Maduro and his supporters have often used the nation’s economic collapse to their advantage, dangling food before hungry voters, promising extra subsidies if he won, and demanding that people present identification cards tied to government rations when they came to the polls.
But participants in the schemes say Mr. Maduro and his supporters have deployed another tool as well: Cuba’s international medical corps.
In interviews, 16 members of Cuba’s medical missions to Venezuela — a signature element of relations between the two countries — described a system of deliberate political manipulation in which their services were wielded to secure votes for the governing Socialist Party, often through coercion.
Many tactics were used, they said, from simple reminders to vote for the government to denying treatment for opposition supporters with life-threatening ailments.
The Cuban doctors said they were ordered to go door-to-door in impoverished neighborhoods, offering medicine and warning residents that they would be cut off from medical services if they did not vote for Mr. Maduro or his candidates.
Many said their superiors directed them to issue the same threats during closed-door consultations with patients seeking treatment for chronic diseases.
One former Cuban supervisor said that she and other foreign medical workers were given counterfeit identification cards to vote in an election. Another doctor said she and others were told to give precise voting instructions to elderly patients, whose infirmities made them particularly easy to manipulate.
“These are the kinds of things you should never do in your life,” said the doctor. Like several others, she spoke on the condition of anonymity because she and her relatives could face retaliation by the Cuban or Venezuelan authorities.
The accounts of manipulation and fraud underscore the many challenges to Mr. Maduro’s legitimacy as president. After the start of his second term in January, the opposition-controlled legislature declared its leader, Juan Guaidó, the country’s rightful president, calling the election undemocratic.
More than 50 countries, including the United States, now recognize Mr. Guaidó as Venezuela’s president, though Mr. Maduro still holds the reins of power.
Mr. Maduro’s opponents often accuse Cuba — which has long depended on oil from Venezuela — of propping up his embattled government by sending agents to work with Venezuela’s intelligence agencies, helping its ideological ally crush dissent.
But the use of Cuban doctors to exert political control is not widely known, the doctors say, and the practice casts a harsh light on a sweeping exchange that supposedly benefits all Venezuelans, regardless of their politics.
The Venezuelan government did not respond to questions, while the Cuban government noted that, for decades, its doctors have been celebrated for their medical missions across the globe, fighting Ebola in Africa, blindness in Latin America and cholera in Haiti, to name a few.
It rejected the doctors’ assertions that they had been dragged into campaigns and pressured to manipulate or threaten patients for political ends in Venezuela, citing the “honorable task” they have accomplished.
“The historical impact of that cooperation in Venezuela has been reflected in the 1,473,117 human lives that have been saved,” the government said.
But human rights experts point to the special pact between Cuba and Venezuela over the last two decades.
“The Cuban government wants to make sure the Venezuelan regime survives and is willing to do anything in their power to support Maduro,” said José Miguel Vivanco, director of the Americas program at Human Rights Watch. “It is unspeakable.”
‘A form of blackmail’
Dr. Carlos Ramírez loved the work.
A dental surgeon, he left Cuba and came to Venezuela, proud of the cause. Many of his patients had never seen a dentist before, he said.
But he despised one part of his job: Each weekend, he and other medical workers were told to hand out medicine and enlist voters for Venezuela’s Socialist Party, he said. The visits were so routine they had a name — “casa-a-casa,” or house-to-house.
“You arrived with vitamins and some pills for blood pressure” or the like, said Mr. Ramírez, who defected to Ecuador after six years. “And when you started to gain their trust, you started the questions: ‘Do you know where your voting place is? Are you going to vote?’ ”
All 16 of the Cuban medical personnel interviewed confirmed the house-to-house visits mixing medicine and politics.
They were part of Barrio Adentro, a program set up by former President Hugo Chávez in 2003 to bring medicine to poor neighborhoods in Venezuela. Under a new Constitution passed in 1999, health care was a universal right. Shifting the nation’s focus to the poor, Mr. Chávez turned to Cuba for medical personnel.
Cuba, still reeling from the collapse of its former patron, the Soviet Union, had much to gain. Doctors are the island’s most profitable export, with medical missions in more than 60 countries that provide Cuba with an estimated $8 billion in cash. Venezuela paid for its doctors in a precious resource: oil.
Mr. Chávez was beloved by many Venezuelans. So in the early years, Mr. Ramírez and other doctors said they were mainly instructed to remind voters that Mr. Chávez had provided the medicine — and should be thanked with their votes.
But in 2013, after battling cancer, Mr. Chávez died. His handpicked successor, Mr. Maduro, was not nearly as popular and faced a strong challenge from the opposition.
Mr. Ramírez and other doctors say they were then told to deliver a warning: If Mr. Maduro lost the election, the next government would break ties with Cuba and Venezuelans would lose their medical care.
“With Chavez it had been hard, but with Maduro, starting in 2013, it was worse,” another Cuban doctor said. “It became a form of blackmail: ‘You’re not going to have medicine. You’re not going to have free health care. You’re not going to have prenatal care if you’re a pregnant woman.’ ”
Four of the Cuban medical workers said the government established “electoral command centers” inside or next to clinics, with Socialist Party operatives dispatching doctors to pressure residents.
One added that, on the day Mr. Maduro was elected to his first term, she witnessed officials opening ballot boxes and tampering with votes, including destroying ballots that chose the opposition. Another said she and others were asked to vote with false identification.
On April 14, 2013, officials declared Mr. Maduro the winner with 50.6 percent of the vote, one of the narrowest margins in years.
“I asked myself, ‘Why is a physician, someone who is meant to be on a humanitarian mission, having a part in who wins an election?’” said one of the doctors. “This is called tampering. There is no other word for it.”
Fake doctors dispensing medicine
By 2015, the headwinds facing Mr. Maduro had grown. Oil prices and production were dropping. The shortages of basic goods had begun. The opposition was seeking control of the legislature, and appeared headed for victory.
“Because the opposition was favored to win, they gave us the work of buying votes,” said Raúl Manuel, a Cuban doctor now in Brazil. “Buying votes in what sense? Going out with medicine.”
Dr. Manuel said he was sent to Barinas, the state where Mr. Chávez was born. But it had begun to turn against the Socialist Party, and resentment against Cuban doctors was building for their pact with the government.
When Dr. Manuel did his required house-to-house visits, some residents unleashed dogs or came to the door armed, he and other doctors said.
On Election Day, Dr. Manuel said he was sent to an opposition stronghold. When early returns showed the opposition ahead, a gun battle broke out. Dr. Manuel said he found himself trapped on a cul-de-sac as bullets ricocheted around him.
He called his clinic for help, he said, but it was busy sending out doctors to get voters to the polls.
“They said they had no cars to rescue us,” he said.
After the shootout, Dr. Manuel said he returned to the clinic, shaken, only to learn that government officials from other departments — including the sports and culture agencies — were going out, too, posing as doctors.
“We, the doctors, were asked to give our extra robes to people,” he said.
The fake doctors were even giving out medicines, without knowing what they were or how to use them, he added.
“They were putting the lives of so many people at risk, the lives of children, all to win votes,” Dr. Manuel said.
Another Cuban doctor in Barinas offered the same account: that government employees, dressed as physicians, were sent out with medicine to get votes.
When the final tally came in, Mr. Maduro’s party had been trounced nationally, losing its majority in the legislature for the first time since 1999.
‘How they controlled people’
By the time Dr. Arias arrived in late 2016, Venezuela was suffering a grinding collapse.
The economic implosion had led to chronic shortages of food. Inflation had hit so hard that people paid with stacks of bills, counted at cash registers with electric bill counters. Crimes and killings soared.
And then there were the hospitals. Vital medicines couldn’t be imported because the government had little cash. Water cuts meant surgeons used bottled water to clean their hands, without soap, which was also in short supply.
Doling out the little medicine that remained, the doctors now focused their vote-getting efforts on patients with chronic illnesses, who needed repeated attention, Dr. Arias said.
“The theme was chronic illnesses, the ones where you would die if patients didn’t get medicine, and that’s how they controlled people,” Dr. Arias recalled.
Mr. Maduro was fighting for control himself. Protests swept the capital for months, setting off a government crackdown in which more than 100 people died in street battles.
After receiving death threats from patients, Dr. Arias said he was sent to a fishing town, La Vela del Coro, where food shortages led doctors and nurses to steal medicine and trade it for groceries.
“I saw it with my own eyes,” he said, recounting how a Cuban nurse traded antibiotics for “a kilo of potatoes, a kilo of yams.”
Residents of La Vela confirmed that both Cuban and Venezuelan doctors regularly bartered medicine for goods on the black market.
In mid-2017, Mr. Maduro made a bid to consolidate power: a referendum for a second legislature to replace the opposition-controlled National Assembly.
Calling the vote illegal, the opposition refused to participate, so the slate of candidates was composed entirely of figures loyal to the president.
The new legislature quickly sidelined the National Assembly, embarking on an aggressive agenda to silence Mr. Maduro’s critics.
The government pushed a contentious identification system called the “homeland card,” used by the Socialist Party for both food subsidies and voting. Mr. Maduro urged citizens to get the card to receive groceries, and party officials opened kiosks outside polling places to review the cards after people cast their ballots.
Dr. Arias said that doctors’ house-to-house visits started registering people for the cards. But the cards terrified many Venezuelans, who feared the government would see how they voted and restrict their food in retaliation.
Before an election for governors that year, Mr. Arias recalled an epileptic patient in the hospital who needed treatment but had refused the homeland card.
“‘I don’t want anything to do with this homeland! I don’t want anything to do with Maduro!’” he recalled her shouting. She was sent away without medication, he said, “because she was from the opposition.”
As the returns came in, Mr. Maduro’s party claimed a lopsided victory, taking 17 of the 23 governorships, despite polls that had projected losses.
“Today, the homeland has gotten stronger,” Mr. Maduro said that night.
‘I argued with my colleagues’
In 2018, it was Mr. Maduro’s turn to face voters.
Measures were taken to ensure his victory. One challenger, Leopoldo López, was dragged between house arrest and a military prison. Another, Henrique Capriles, was banned from running, along with most opposition parties.
But his government withheld other essentials.
Dr. Arias said medical supplies, always scarce in La Vela, soon disappeared, hoarded until the May election. He said his superiors wanted to flood hospitals with supplies right before the vote, giving the impression that Mr. Maduro had fixed the country’s shortages.
“When the elections came, everything appeared: medicine, gas, dressings for bandages, injection serums,” he said. Residents in La Vela who had gone to the clinic confirmed it was suddenly supplied before the election.
The case of the oxygen tanks still weighs heavily on Dr. Arias.
“I argued with my colleagues over and over,” he said. “Yes, of course there was oxygen, but they didn’t let me use it.”
Ángel Villegas, La Vela’s opposition mayor, said he was denied medication, too, told that it was in short supply.
“There are a large number of services where you feel that, yes, they took into consideration the fact that you were in the opposition,” he said.
As Election Day neared, the doctors continued to fan out in support of Mr. Maduro.
“They come to your house, they ask you a series of questions, and you start to think, if I answer ‘no,’ they can cut me from health care,” said one patient, who declined to be named, fearing government reprisals. “It just leaves you overwhelmed.”
On May 20, Mr. Maduro was declared the winner, landing him a second term. For Dr. Arias, it was too much.
He made his way to Chile, taking shelter in a church, cleaning floors in a hospital and seeking asylum, unable to find work as a doctor.
“If I can’t be a doctor, I at least want to be a person,” he said.
It’s unclear how many other doctors have abandoned Cuba’s medical missions around the world — informal estimates are in the thousands — but the consequences are stark. Dr. Arias and the others are considered deserters by the Cuban government and cannot return to their families.
Dr. Ramírez, the dental surgeon, is one of the few doctors interviewed who has returned to medicine, with a small practice in Ecuador.
“You don’t finally realize what is right, until you open your eyes,” he said.