initiatives; "cubans, with the help of venezuela, are currently educating more doctors, about 70,000 in all, than all the medical schools in the united states, which typically have somewhere between 64,000 to 68,000 students enrolled in their programs". elam selects students from a working class background who would not be able to afford university otherwise.: 279 effects on cuba benefits both humanitarian and ideological factors were prominent in cuba's "doctor diplomacy", particularly during the cold war. subsequently, its continuation has been seen as a vital means to promote cuba's image abroad and prevent international isolation. cuba's health missions in honduras were "undoubtedly a deciding factor" in the re-establishment of diplomatic relations between the two countries in 2002, ; guatemala re-established diplomatic relations with cuba in 1998. at the 2009 5th summit of the americas, u.s. president barack obama commented that at the summit he had heard much about the impact of cuban "soft diplomacy" in the form of its medical internationalism. he said this might be a reminder to the united states that limiting its interactions with latin american countries to military and drug interdiction might be limiting its influence. it has also been suggested that cuban medical internationalism promotes exports of cuban medical technology, and may be a source of hard currency. however, the targeting of poor countries reduces the hard currency potential of missions abroad. in 2006, cuba's earnings from medical services, including the export of doctors, amounted to us$2,312m – 28% of total export receipts and net capital payments. this exceeded earnings from both nickel and cobalt exports and from tourism. these earnings were achieved despite the fact that a substantial part of cuba's medical internationalism since 1998 has been organised within the framework of the "integrated health program" (programa integral de salud, pis); this cooperation program is free for the receiving country. cuba's co-operation with venezuela provides cuba with cheap oil in exchange for its medical support to mission barrio adentro. bloomberg reported in march 2014 that cuban state-controlled media forecasted revenue of $8.2 billion that year from the program. it has also been argued that the program has, particularly in the 1980s and 1990s, "perform a critical function in consolidating socialist consciousness" within cuba. costs although cuba's large-scale medical training programs and high doctor-patient ratios give it much latitude, the expansion of doctor diplomacy since 2004, particularly with the barrio adentro program, has been dramatic: the number of cuban doctors working abroad jumped from about 5000 in 2003 to more than 25,000 in 2005. this has had some impact on the domestic health system, for example there have been increased waiting times, particularly with regard to family doctors. the number of patients per doctor rose from 139 to 179. in march 2008 cuba announced a reorganisation of its domestic family doctor program for greater efficiency. possible effects of lifting the u.s. embargo a 2010 article by laurie garrett in foreign affairs warned that lifting the united states trade and travel restrictions on cuba could have dire consequences for cuba's health care system, leading to an exodus of thousands of well-trained cuban health-care professionals. u.s. companies could also transform the remaining health care system into a destination for medical tourism. garrett concluded that, if politicians do not take great care, lifting of the restrictions would rob cuba of its greatest triumph. reports of slavery and political coercion the united nations high commissioner for human rights, in an official public communication by the mandates of the special rapporteur on contemporary forms of slavery, including its causes and consequences; and the special rapporteur on trafficking in persons, especially women and children, have indicated that the working conditions of the cuban medical workers in these missions "could rise to forced labor, according to the forced labor indicators established by the international labor organization. forced labor constitutes a contemporary form of slavery". in particular, related to defection the communication indicated that "if a professional decides to retire from work abroad, it is classified as «abandonment of the mission of civilian workers» under the cuban penal code, which in its article 135.1 stipulates that «the official or employee in charge of fulfilling a mission in a foreign country that abandons it, or, once it has been completed, or required at any time to return, refuses, expressly or tacitly, to do so, incurs a punishment of deprivation of freedom for three to eight years.»” according adn cuba, the cuban government keeps between 70 and 90% of their additional salary paid by the host country and those who break the mission are punished for 8 years, without allowing them to return to cuba. according to a 2019 the new york times article, sixteen cuban doctors from mission barrio adentro in venezuela denied medicine and other treatments in order to secure votes for the united socialist party of venezuela (psuv) during elections through coercion. the report said this occurred during 2018 venezuelan presidential election in which nicolás maduro won reelection. cuban doctors would have been instructed to go door to door warning residents that medical treatments would be cut off if they did not vote for maduro. they also were asked to register people into the venezuelan government homeland card, to secure medical services, and refuse treatment to those who did not apply for it. some doctors report to have provided counterfeit id cards to patients to be able to vote. according to four doctors, maduro administration established electoral command centers next to clinics led by members of the psuv to dispatch doctors to pressure residents. according to human rights watch "the cuban government imposes draconian rules on doctors deployed in medical missions globally that violate their fundamental rights". defection of cuban medical professionals in 2000, two cuban doctors working in zimbabwe attempted to defect to canada. they were prevented from doing so by two zimbabwean soldiers, who handed them over to cuban officials. united nations officials said zimbabwe appeared to have violated national and international laws. according to a 2007 paper published in the lancet medical journal, "growing numbers of cuban doctors sent overseas to work are defecting to the usa", some via colombia, where they have sought temporary asylum. in february 2007, at least 38 doctors were requesting asylum in the u.s. embassy in bogotá after asylum was denied by the colombian government. cuban doctors who defected said that they were monitored by "minders" and subject to curfew. cuban medical professional parole program in august 2006 the united states under george w. bush created the cuban medical professional parole program, specifically targeting cuban medical personnel and encouraging them to defect while working outside cuba. from an estimated 40,000 eligible medical personnel, over 1000 had entered the united states under the program by october 2007, according to the chief of staff for u.s. rep. lincoln díaz-balart. by 2017, more than 7000 had entered the program. the promised fast-track visa was not always forthcoming, with at least one applicant having to wait a year for his visa; although according to julio césar alfonso of the cuban dissident organisation "outside the barrio," the u.s. government has rejected only a handful of the hundreds of applications for visas. critics of the us program described it as "immoral" because it takes medical professionals from the world's poorest nations to one of the world's wealthiest nations. on 12 january 2017, president obama announced the end of the program, saying that both cuba and the us work to "combat diseases that endanger the health and lives of our people. by providing preferential treatment to cuban medical personnel, the medical parole program contradicts those efforts, and risks harming the cuban people".