This Just In — A Message from Cuba
This Just In—A Message from Cuba
Special Coverage
At the end of february, I had an opportunity to travel within cuba for the American Council of Learned Societies to review funding proposals in collaborative projects for U.S.-Cuban exchange in the social sciences, as well as the natural sciences. Being "the token" science person, I reviewed several HIV projects and was struck with the differences in Cuba’s approach to AIDS since my last visit in 1983. At that time, I gave a lecture about HIV at "Instituto Pedro Kouri" and was bluntly told that homosexuality and drugs did not exist on the island, so AIDS would never become an imposing issue.
In 1985, when the first cases of AIDS occurred among international workers returning from Angola, Cuba allotted 310 million U.S. dollars for HIV testing equipment. In 1986, the Cuban Ministry of Health instituted HIV screening for large segments of the population and mandatory quarantine of HIV-positive citizens at a sanitarium in Havana. Mandatory tracing and testing of sexual contacts for people identified as HIV positive is considered by Cuban officials to be the reason for the lowest HIV prevalence reported in our hemisphere. As of June 1997, Cuba reported 1609 HIV-positive citizens out of a population of 11 million; now, the official number is 2500 (personal communication—Dr. Gustavo Kouri).
This policy drew charges of human rights violations, and, in response, the Cuban AIDS program evolved. Dr. Jorge Pérez Avila was effectively made director and liberalized the policies of the Sanitaria, as well as overseeing the construction of 13 additional Sanitaria in each province of Cuba. This allowed HIV-positive residents to move closer to their communities, setting the stage for the alternative, ambulatory HIV care which began in 1993. Strong educational programs were coupled with condom initiatives—the latter initiative fraught with cultural difficulties in acceptance.
Public health and universal access to free medical care have been priorities for Fidel Castro’s government since its inception in 1959. Polio, malaria, tetanus, diphtheria, and human rabies have been eradicated from the island. Preventive health care is delivered by general practice doctors and nurses through the "Family Doctor Program" (in which one doctor and one nurse are assigned personal responsibility for each neighborhood of 100-200 Cuban families). They are required to design preventive health education programs for the neighborhood and are held accountable for any deaths or disabilities that occur in their assigned neighborhood. Cuba now has twice as many physicians per capita than the United States and an infant mortality rate of 7.9/1000 births.
The U.S. embargo has begun to encroach upon the health of Cuban citizens by engendering widespread drug and equipment shortages. Mergers of European suppliers with U.S. companies have suddenly cut off parts and equipment, including supplies of reagents for blood work involved in monitoring CD4 counts for HIV-infected patients. Protease inhibitors made by U.S. pharmaceutical companies are totally unavailable unless mailed by family members.
Currently, most people newly diagnosed with HIV infection are asked to enter the Sanitaria for six months to a year at which time they participate in an intensive course covering mental and physical hygiene, and safe sexual practices, and in which they are given expensive medical regimens, such as AZT and DDT for free. Sanitaria residents received their full wages or public assistance without working, received above average housing accommodations, and a supplemented diet with animal protein and calories (a diet that is currently strictly rationed for the general population). In contrast, ambulatory patients must support themselves financially although they are all eligible for both special protein rations and medications free of charge.
On a personal note, I was struck with the difference in the healthcare system between Cuba today and 15 years ago. The human consequences of our embargo are all too evident on the wards of the hospitals, and in the faces of children lacking medications for treatable diseases such as leukemia, heart diseases, and even diabetes when serious shortages of insulin occur. Sharp declines in food imports and agricultural machinery have resulted in significant signs of nutritional deficits, most notably in the 1993 neuropathy epidemic that temporarily blinded more than 50,000 Cubans, but also with the dramatic decrease in median weight of both children and adults as foods at workplaces and schools are cut back and food supplies become scarce.1
To end on a more hopeful note, I was struck by the increasing tourist trade in Cuba and the openness to discuss the failures of the revolution as well as its successes. The recent Clinton initiative is widely seen as a meaningless gesture culminating in a baseball game and transfer of money to relatives of exiles whom have been already receiving assistance. Clearly, the Cuban health system has been crippled by our embargo, yet the courage, dedication, and spirit of our Cuban healthcare colleagues is inspiring. I can only hope for the day our government realizes economic sanctions for political purposes have a profound effect on the health and nutrition of innocent children as well as adults. —MICHELE BARRY, MD
Reference
1. Román GC. Epidemic neuropathy in Cuba: A public health problem related to the Cuban Democracy Act of the United States. Neuroepidemiology 1998;17:111-115.
Editorial comment— "Eisenberg (N Engl J Med 1997;336:1248-1250) has correctly pointed out that the primary cause of these epidemics in Cuba is the U.S. restriction on trade, and he reminded physicians that, like John Snow petitioning the Board of Guardians of St. James Parish to remove the handle of the contaminated Broad Street water pump to control the cholera epidemic in London, we have a responsibility to petition authorities to remove known causes of epidemics.
"In the early days of navigation, the yellow flag indicating an epidemic aboard ship was respected by all nations regardless of the vessels’ nationality. This international respect for epidemic diseases led in turn to the development of public health policies that go beyond the internal political interests of a given nation. Examined from the public health perspective, the inflexible position of the U.S. government in maintaining a restrictive policy—unambiguously calculated to cause harm to the health of another nation—appears unduly vindictive and inconsistent with the United States’ tradition of justice and respect of freedom."1
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