“The Threat of a Good Example”: Health and Revolution in Cuba
by
Aviva Chomsky
from
Dying for Growth: Global Inequality and the Health of the Poor
edited by
Jim Yong Kim, Joyce V. Millen, Alec Irwin, and John Gershman

 

Cuba’s lower per capita expenditure to achieve health indices similar to those of the developed countries suggests that health care is not as expensive as one might imagine. It also suggests that health care alone does not improve a population’s well-being, but that meeting the entire population’s basic human needs, including medical services, through resource distribution does. Money is necessary but not sufficient to improve a people’s health. Government intervention is essential to guarantee access to health care and to guarantee, therefore, greater effectiveness of the medical system. Comparisons of Canada, the United States, and Britain ‘suggest that among these three countries health is inversely related to health-care costs, but directly related to the degree of governmental intervention in health-care delivery.’ Cuba’s government is the sole provider of health care, and gives high priority to allocating resources—fiscal, physical, and human—to achieve its health goals.  Julie Feinsilver
 

How it must pain them that.. .we can speak of an infant mortality rate of under ten, and even under nine, after a minimum of five years of the special period! How painful must be the news that life expectancy has increased, that, in spite of the shortage of resources and medicines, our doctors are constantly making ever greater advances! How can this Cuban miracle be compared with what we know is occurring in other parts of the world and particularly in Latin America? And they’ve wanted to destroy our country, they have even wanted to charge us with human rights violations, when the lives of approximately one million children and young people have been saved by the work of the Revolution.. . . It is the reverse of what happens everywhere else and of what is advised everywhere else by the World Bank, the International Monetary Fund, and the United States: all those neoliberal theories that you’re familiar with, all those practices, throwing out tens of millions of workers onto the streets, closing schools, closing hospitals, eliminating essential public services...what capitalist country has achieved the level of social security, of social justice that our country has attained, of respect for the people attained in our country?  Fidel Castro
 

            Most of the chapters in this collection explore the ways in which the so-called “New World Order,” and in particular the economic programs associated with neoliberalism and structural adjustment, have under­mined the health of the poor. They show that from the most basic humanitarian perspective, structural adjustment and neoliberalism are simply unac­ceptable alternatives. This chapter seeks to show that the results of neoliberalism are not only morally unacceptable, but also completely unnecessary. It is in fact quite pos­sible for a poor, Third World country to protect the health of its population, even under circumstances of extreme economic privation. It is no accident that the coun­try that disproves the assumptions behind the argument, Cuba, is virtually always left out of mainstream analyses that attempt to defend neoliberal reforms.

    A close examination of health and revolution in Cuba brings into sharp relief some of the false assumptions underlying current discussions of economic adjustment and health. Where mainstream studies argue that “development” in standard terms— that is, an increasing GNP—is a prerequisite for improving the health status of a coun­try's population, the Cuban example suggests that distribution of resources within a country is more important than the overall GNP in affecting health outcomes. Where mainstream approaches argue that any of the economic choices available to poor countries will require sacrifices in the area of health care for the poor, the Cuban example shows that in fact there are economic options that distribute the sacrifices differently. Where many analysts argue that structural adjustment can be made acceptable by targeting vulnerable sectors with specific programs, the Cuban example shows that massive social change is much more effective than targeting for improving the health of the poor. Cuba shows that First World health standards are indeed pos­sible in a Third World economy. For precisely this reason, most studies of economic reform through austerity and adjustment ignore the example of Cuba.


HEALTH AND REVOLUTION

At the time of the 1959 revolution, Cuba’s health profile, and its health-care delivery system, were fairly good by Third World standards, although aggregate sta­tistics masked enormous regional, racial, and class inequalities. Access to adequate food and shelter, as well as to medical care per se, was dependent on one’s economic standing. In their study of food and nutrition in Cuba, Medea Benjamin, Joseph Collins, and Michael Scott summarize the situation in the 1950s:

 

While Cuba had the highest ratio of hospital beds to population in the Caribbean, 80 percent were in the city of Havana. Havana province had 1 doctor for every 420 per­sons, but rural Oriente province had 1 for every 2,550. Unsanitary housing and poor diets made curable diseases widespread. The World Bank reported in 1951 that between 80 and 90 percent of children in rural areas suffered from intestinal parasites. In 1956, 13 percent of the rural population had a history of typhoid and 14 percent tuberculosis.

 

Large sectors of the population had access neither to medical care nor to ade­quate food and shelter.

The 1959 revolution aimed at liberating Cuba from the dictator Batista, but more profoundly from the relationship with the United States that many Cubans felt had replaced Spanish colonialism with U.S. neocolonial political and economic domination. The Cuban independence leader José Martf (1853-1895) had spoken of the dual goals of social equality and national independence as one. But these hopes were dashed by the U.S. invasion of Cuba in 1898. Although the United States eschewed direct political rule, its subsequent control of the island stifled the Cuban independence project of the nineteenth century—the project of building a nation “with all and for the good of all.” The 1959 revolutionary project aimed at fulfilling, concurrently, the goals of national independence and social justice.

Julie Feinsilver argues in her study of health and revolution in Cuba that “the central metaphor in Cuba’s anti-imperialist struggle. ..is that of health. The health of the individual is a metaphor for and a symbol of the health of the ‘body politic’.... Medical doctors.. .are warriors in the battle against disease, which is largely considered a legacy of imperialism and underdevelopment.” While there are certainly political and perhaps even symbolic reasons for the Cuban government’s prioritizing the health of the population, this chapter focuses on the real impact of the revolution’s commit­ment to health. Propaganda aside, the government has been extraordinarily success­ful in promoting the health of the population.

The Cuban revolution’s commitment to the health of the country’s popula­tion is notable in several respects. First, the government understands health to be the responsibility of the state. Second, the government approaches health as a social issue that includes health-care delivery but is far from limited to it. Thus, the state is responsible not only for building, maintaining, and ensuring universal access to doctors, clinics, and hospitals, but also for guaranteeing and sustaining the social conditions necessary for health: universal access to education, food, and employment. Feinsilver paraphrases a 1961 Cuban Health Ministry report entitled “Economic Underdevelopment, the Principal Enemy of Health: How the Cuban Revolution Combats It,” which argues that:

 

The true eradication of misery and real improvement in health would occur only through revolution, that a band-aid approach would not eliminate disease.... [M]edicine alone will not improve the overall health of the population. What will improve it.. .is embedding medicine within a significant transformation of the socio­economic structure to eliminate the problems of underdevelopment: the legacy of hunger, illiteracy, inadequate housing, discrimination, and the exploitation of labor.

 

Third, the government has insisted that health is a national project, with pop­ular participation an integral element. Block committees and mass organizations par­ticipate in sanitation, vaccination, and education campaigns. Community workers collaborate closely with health professionals in overseeing clinics, diagnosing health problems in the community, promoting people’s health schools, and designing future health strategies.

Finally, Cuba has rejected the idea that Third World governments must settle for an “appropriate” level of health care, in which cost-effective public health and preven­tive measures are emphasized to a greater degree than more costly hospital-based and curative care. The Cuban revolution succeeded in developing both an effective public health, preventive, and primary care system and an advanced tertiary care system. In addition to being up-to-date, well-staffed, and involved in cutting-edge research, the tertiary care system is free and universally available to the country’s population.

Thus, the Cuban revolutionary approach to health has involved several differ­ent levels; radical social and economic transformation has created an egalitarian society in which the entire population is guaranteed access to food, employment, and education. In addition, the government has rebuilt a health-care delivery system aimed at both public and preventive health and at universally accessible, high-tech, hospital-based care. The results of these state policies are clear to any observer who cares to look at the statistics: Cuba, a country with a Third World economy, boasts a first-world health profile. It demonstrates that excellent social and particularly health outcomes are possible without major economic “development” as measured by GNP or other standard measures.

As illustrated in Table 13.1, Cuba stands out among Latin American countries with respect to its health and social indicators. Despite its low per capita GDP, Cuba has the lowest infant mortality and under 5 years old mortality rates in Latin America. These indicators are, in fact, comparable to those found in the world’s wealthiest countries. Cubans have a longer life expectancy at birth and are more educated than most of their Latin American counterparts. They enjoy one of the highest daily per capita calorie supplies in the world. Though Cuba is indeed poor in purely economic terms, Table 13.2 demonstrates that health has been an important priority for the country. Cuba’s public sector spending on health as a percentage of GDP exceeds that of most countries. Other health and social indicators are more comparable to high-income countries than to other low-income countries.

Cuba also stands out for its regional equality. Over the last 15 years, the gov­ernment has invested considerable effort in mitigating social and health discrepancies among regions of the country. Although income levels among provinces still vary, Cubans from every province, even the poorest, are well provided for in terms of health. These efforts, as illustrated in Table 13.3, are apparent when Cuban health outcomes are examined by region.

The role of the state has been key in Cuba’s socioeconomic transformation and in its health-care delivery system. State control of the economy has meant that resources can be allocated, distributed, and shifted, based on ongoing assessment of needs. Excellent information gathering systems and government commitment to the health of the population have allowed problems to be systematically identified and resources channeled to address them. The Pan American Health Organization (PAHO) noted in a 1994 report that Cuba’s health profile has been surprisingly resis­tant to the economic crisis which the country has suffered since 1990. The report sum­marized the reasons for Cuba’s ability to sustain good health in these terms: “the great capacity and effectiveness of the National Health System; the high cultural level of the Cuban people and their active participation in social and health programs.. .the health consciousness of the population, who consider health one of the country’s greatest social triumphs; and Cuba’s social and health policies, which have main­tained their priorities despite the current difficult conditions.”

The importance of centralized planning in translating the government’s com­mitment to health into effective outcomes can be seen with particular clarity in the Cuban response to three important health problems during the past 20 years: an outbreak of dengue fever in 1981, the discovery of AIDS in Cuba in 1986, and an epidemic of neuropathy in 1993. In all three cases human, material, and scientific resources were mobilized rapidly and successfully to confront these illnesses. Because these cases illustrate so well ways in which political, social, and health fac­tors interrelate, I briefly discuss each here.

DENGUE FEVER

Dengue fever is a mosquito-borne viral illness. There are four known strains of the dengue virus (labeled dengue-1 through dengue-4), any of which can lead to dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS). Ordinary dengue is characterized by high fever, vomiting, and intense and debilitating mus­cular, abdominal, and head pain. For DHF and DSS, recent studies suggest that these potentially lethal complications of dengue may be partially immune-mediated and are seen most often in patients serially infected with two different strains.

Dengue outbreaks have occurred in the Caribbean since the 1950s, but Cuba did not have a case of the virus until 1977, when a Caribbean epidemic of dengue-1 struck the island. Although the epidemic struck hard and spread rapidly, it did not develop into cases of either DHF or DSS. In fact, both DHF and DSS had rarely occurred outside southeast Asia and the western Pacific and never (at least in this century) in the Americas. However, when a dengue-2 strain hit Cuba in 1981, it led to numerous DHF cases and fatalities. Cuban researchers hypothesized that a combi­nation of relative lack of immunity among the population, heavy infestation with the Aëdes aegypti mosquito carrier, and the sequence and timing of exposure to the differ­ent strains of the virus contributed to the outbreak and severity of the epidemic.

When dengue-2 appeared in Cuba in May of 1981, it spread rapidly, reaching epidemic proportions within a month; 344,203 cases were recorded during the four-month period (June-September) that the epidemic lasted. Of these, 9,203 were clas­sified as World Health Organization (WHO) level III, or “serious,” and 1,109 as level IV, or “very serious.” A total of 158 people died.

The Cuban government mobilized against dengue on two fronts: in identifying and providing supportive medical care to those affected by the disease, and by orga­nizing a massive popular sanitation campaign to eradicate the mosquito that carried the disease. As Feinsilver describes it, “the nation was put on war footing to do battle against dengue.” The media, schools, workplaces, mass organizations, and neighbor­hoods were mobilized all over the country to eliminate breeding places and apply lar­vicides, and to identify people with symptoms of dengue and ensure that they received medical care. Under what Cuban doctors called a “liberal hospital admission policy,” 116,151 patients (37 percent of those infected) were hospitalized. This was probably an important factor in reducing fatalities: “In other epidemics elsewhere, where the index of hospitalization was typically much lower, patients were hospitalized when they were already in shock, and the indexes of mortality and lethality were higher.”

In addition to curative care, the government launched “an intense anti-Aëdes campaign. ”In June the government initiated a massive spraying of malathion and an education campaign to eliminate breeding areas. On July 26 Castro announced the second phase—the fumigation of every house in Cuba and the treating of all water deposits with insecticides. A “health army” of over 13,000 was trained to oper­ate 5,000 backpack larvicide sprayers to inspect and eliminate breeding places. In mid-August, the Soviet Union donated a fleet of fumigation trucks. The director general of the WHO lauded Cuba’s efforts on a visit to the island in August, stating: “The strategy defined by the Cuban government is highly valid, and I am sure that it will be crowned by success.” And it was. Within four months the disease had been eliminated: the last case was recorded on October 10. “No government in the Third World and few in the developed countries could have achieved as much as rapidly as the Cubans did, because most lack this national capacity to mobilize,” concludes Feinsilver. In fact, the Latin American dengue pandemic continues elsewhere with record-breaking numbers of cases and record-breaking mortality.

The dengue campaign demonstrated how a national commitment and a national mobilization could successfully contain a disease. Feinsilver argues that the mobiliza­tion was fueled by Cuban accusations that the C.I.A. had deliberately introduced dengue into the country. Thus, the battle against dengue was of symbolic importance in Cuba's battle against the United States; it was promoted in Cuba as a struggle against imperialism. Whatever the true cause of the epidemic, Cuban medical professionals and the Cuban health system focused on confronting and eradicating it. Cuba’s battle against dengue could have served as a model to other countries for dealing with a pub­lic health emergency; it could have been lauded as an example of a successful public health response. However, it was not. The U.S. media concentrated on ridiculing Castro’s suggestion that the C.I.A. may have been behind the epidemic, and celebrat­ing the fact that the U.S. government had generously made an exception to its embargo and granted the PAHO permission to purchase insecticides produced in the United States for use against the dengue-bearing mosquito in Cuba.

HIV/AIDS

If the success of Cuba’s anti-dengue campaign was overlooked by the U.S. media, its AIDS policies have not been. In fact, Cuba’s policies on AIDS tend to receive greater media coverage than the rest of its health system—even though as of January 1996, Cuba had only 1,196 diagnosed HIV-positive cases, making it one of the least important health problems on the island. Cuba’s policies have also received much greater coverage than the AIDS policies of neighboring Caribbean islands where the prevalence of AIDS is from ten to over one hundred times greater. Because Cuba’s AIDS policies are so controversial, they merit special attention. I will go into some detail regarding the ways Cuba’s AIDS programs have been discussed abroad, the evolution of the policies themselves, and what Cuba’s AIDS policies— along with foreign responses to them—reveal about politics and health.

HUMAN RIGHTS AND AIDS

United States attention to Cuba’s AIDS programs has been framed as a denun­ciation of human rights violations rather than a discussion of health care. Key themes in U.S. media accounts have been Cuba’s initial policy of quarantine for those diagnosed as HIV-positive (discussed in detail later in this chapter) and, in particular, Cuba’s discriminatory policies against homosexuals. United States media accounts have been fairly consistent in focusing on the issue of freedom for those diagnosed HIV-positive and the ethical issues surrounding mandatory testing, rather than the health aspects of Cuba’s AIDS programs. Ethical issues, however, have been narrowly defined by the U.S. media as individual independence from state interference. In this formulation, access or lack of access to medical treatment (much less to minimal stan­dards of nutrition and shelter) is not an ethical issue—thus, few articles discuss the ethics of U.S. AIDS policies.

To Cubans, it seems absurd that U.S. critics could bring up the issue of human rights in discussing Cuba’s policies toward AIDS. “It seems very important to define our concepts of discrimination, exclusion, and human rights,” explained Vice Minister of Health Hector Terry:

 

In Cuba, nobody lacks economic resources because of being an AIDS carrier. In Cuba, no one dies abandoned on the streets for lack of access to a hospital. In Cuba, we haven’t had to open hospices so that patients who have been abandoned have a place to die in peace. In Cuba, no one’s house has been set on fire because its inhabitants are people with AIDS. In Cuba, no homosexual has been persecuted because he’s assumed to be likely to spread the virus. In Cuba, we don’t have the problem of national minorities or drug addicts with high rates of AIDS.

 

United States health-care professionals have been much less sensationalist in their assessments of Cuba’s AIDS policy than has the mass media. A member of the first delegation of U.S. health professionals (from Columbia University), which vis­ited Cuba’s Santiago Las Vegas Sanitarium in late 1988, described the sanitarium as “a complex of homes near Havana airport, modest by U.S. standards, but not by Cuba’s, with air-conditioners and color television. The medical staff was large....” Another member of the visiting delegation stated that the facility comprised “groups of non-descript apartments that looked like typical Cuban suburban housing. It was neither barracks-like nor dungeon-like.” However, the U.S. media seized upon words like “involuntary”; “quarantine”; “human rights violation”; “totalitarian”; ‘‘prison’’; and ‘‘rigid surveillance.’’ They chose to focus upon the ‘‘ethical’’ issues involved—failing themselves to discern any ethical problems in the U.S. govern­ment’s unwillingness to provide adequate medical care for many of those infected with HIV or to take any significant steps to halt the rapid spread of the disease.

HOMOSEXUALITY, THE EPIDEMIOLOGY OF AIDS IN CUBA,

AND THE POLITICS OF BLAME

There is some disagreement among those studying the infection as to whether HIV/AIDS in Cuba is primarily a disease of homosexuals or of heterosexuals and in particular whether discrimination against homosexuals is connected to Cuba’s AIDS policies. This is a question of political as well as epidemiological import since the issue of human rights is so intimately tied with U.S. studies of Cuba’s AIDS policies. Many U.S. studies critical of Cuban AIDS policies in human rights terms argue, implicitly or explicitly, that these policies are part of a larger societal and governmental dis­crimination against homosexuals. There is often a hidden assumption that somehow the charge that Cuba’s policies violate human rights is more credible, or is magnified, if HIV/AIDS is shown to be associated with homosexuality.

The results of the extensive testing carried out in Cuba and follow-up statistics on the characteristics of those testing positive for HIV can give us some idea of the epidemiology of HIV and AIDS in Cuba. First, and most strikingly, the rate of HIV and AIDS infection in Cuba is quite low by international standards. Among those tested by May of 1988, the highest rates were, predictably, found among sexual con­tacts of HIV seropositive people (4.5 per 100). Among other “high risk” groups the HIV positivity rate was low compared to the rest of the Americas: among STD patients it was 0.0 16 per 100; among hospitalized patients it was 0.003 per 100; among prisoners, 0.01 per 1002~

Nancy Scheper-Hughes wrote in 1993 that “a large number of Cuban soldiers returning from Africa” were found seropositive in these initial tests. Scheper-Hughes defends Cuba’s policies by emphasizing that Cubans first encountered HIV in 1986 among soldiers returning from Africa. This was the reason the AIDS sanitarium was at first under the authority of the military: it was a facility for soldiers. Later, in 1986, the disease was discovered among civilians through testing at neighborhood clinics.

Many among this second group of seropositive civilians were homosexuals. Thus, in 1987 the sanitarium was transferred to the Ministry of Public Health: 

 

AIDS is not viewed as a disease of the sexually stigmatized. Over 60 percent of seropositive Cubans are heterosexuals, many of whom were infected overseas on mil­itary duty. ..or were the sexual partners of such people on their return. AIDS tends to be viewed in Cuba as an occupational hazard of internationalists, and these are hardly a stigmatized population.

 

Hector Terry, however, did associate AIDS with homosexuality, at least initially. As Vice Minister of Health, he reported that, in the first round of massive testing, none of the pregnant women and a “low number” of returning soldiers diagnosed positive for the infection. The Cuban media reported in 1986 that HIV had entered the country in 1982 through a Cuban who had become infected in New York, a claim repeated by Terry in 1987.40 It then spread, according to these sources, among the homosexual community and through bisexual men to heterosexuals. It is not certain, however, that identifying homosexual transmission of AIDS is inherently homophobic. A polit­ical scientist who has studied the situation, in fact, makes contradictory arguments to imply the homophobic nature of the debate about AIDS transmission in Cuba. He gives some examples where officials identify homosexual transmission, and others where they fail to identify homosexual transmission, and labels both of these phenom­ena as examples of homophobia.

The debate about how HIV/AIDS got to Cuba is complicated by a number of factors. Given the history of U.S. bacteriological warfare against Cuba, some Cuban officials almost automatically assumed and explicitly argued that AIDS was another weapon in the U.S. arsenal against the island. United States officials, in response, have blamed Cuban “military adventures” in Africa. And Cubans, in defending their African policies, have downplayed the African connection. Using arguments about the prevalence of AIDS among volunteers who had served in Africa, Scheper-Hughes attempted to defend Cuban policies against charges that they constituted discrimina­tion against homosexuals. However, I have found no Cuban sources which agree with her interpretation of the origin of AIDS in Cuba. If there is any “politics of blame in Cuban medical or popular culture, it is against foreigners in general and the United States in particular, rather than against homosexuals or Africa. It tends to be foreign human rights activists and gay rights activists who emphasize the association of homo­sexuality and HIV in Cuba.

To shed further light on the epidemiology of AIDS in Cuba, let us examine the available statistics. Sexual transmission accounts for virtually all cases of HIV infec­tion in a country in which injection drug use is rare and the blood supply has been tested for HIV antibodies since 1985, shortly after the development of serologic test­ing. In late 1988, the gender breakdown of those testing HIV-positive over the prior two years was 170 men and 70 women; in April 1989, it was 195 men and 73 women; about 65 percent of the men were homosexual or bisexual. A 1989 study of risk fac­tors among those infected with HIV showed that of the 315 men infected with the virus, 105 were gay or bisexual, while sexual contact with foreigners was the princi­pal risk factor in 217 cases. A visitor in 1989 was told that “about a third of the 171 male residents [in the Santiago Las Vegas sanitarium] were homosexual or bisexual.” In September of 1990, there were 497 total cases of HIV infection, 362 male and 135 female; 150 had acquired the infection through homosexual contact, and 325 through heterosexual contact. July 1992 statistics showed 579 men and 233 women infected with H1V; at the end of 1992, the director of the AIDS Advice and Information Center in Havana stated that of the 703 people in the sanitaria, 41 per­cent were homosexual or bisexual and 57 percent were heterosexual. In March 1994 Ministry of Health statistics showed 1,011 total cases of HIV, 71 percent of these men and 29 percent women, with 446 (44.1 percent) identified as acquired through homosexual or bisexual transmission, 549 (54.3 percent) through hetero­sexual transmission, and the remaining 16 through transfusions, hemophilia, occu­pational, or perinatal transmission. Lumsden notes that the proportion of seropos­itive males who are homosexual or bisexual rose from 41 percent in October 1990 to 62.8 percent in December 1994.51 Thus there exists evidence both for the impor­tance of homosexual transmission, and for noting that it is not the primary means of transmission.

More important than determining the degree to which HIV/AIDS is a disease associated with homosexuality in Cuba is examining how the real, though not exclusive, association between AIDS and homosexuality has affected Cuba’s AIDS policies. The opinion of U.S. medical experts who have studied Cuban AIDS poli­cies is virtually unanimous in arguing that Cuban policies toward AIDS are absolutely consistent with its policies toward other diseases and epidemics and with its health-care system as a whole)Both critics and cautious admirers of the poli­cies agree that “Cuban health officials have viewed the AIDS-control program as an extension of the post-revolutionary health-care system.” Lumsden writes that “the quarantine measures were quite consistent with Cuba’s radical response to other epidemics such as dengue and African swine fever.” Swanson, Gill, Wald, and co-workers argue that “from the outset, Cuba treated HIV/AIDS as a health problem rather than a social or political problem. Cuba’s response to the AIDS epi­demic was no different from the response of the country to any other outbreak, such as meningitis or gastroenteritis.” Scheper-Hughes goes further and argues that the tendency in the United States to approach AIDS as a social rather than a medical problem severely limited the public health response and contributed to the spread of the disease:

 

In the United States and Europe human rights issues were seen as central from the very start of the epidemic. Arriving as it did on the heels of the sexual revolution and the feminist, gay rights, and patients’ rights movements, AIDS was seen as a major test of our commitment... the rights agendas already in place provoked a ‘hands off’ response so virulent that we lost sight of the real threat. As Stephen Joseph, former Commissioner of Public Health for the City of New York told me in May, 1993, ‘We came to think of AIDS as fundamentally a crisis in human rights that had some public health dimensions, rather than as a crisis in public health that had some important human rights dimensions.’ This perception is reflected in the mountain of uninspiring social science literature on AIDS, a morass of repetitive, pious liturgies about stigma, blaming, and difference. These writings conceal a col­lective denial of the impact of AIDS....

In the United States blood screening was delayed because of the implications of asking donors to identify sexual practices and drug habits. HIV testing was not added to the work-up of every newly admitted hospital patient, and neighborhoods with a superabundance of HIV seropositivity were not targeted for intensive treat­ment and prevention programs for fear of stigmatizing certain postal code districts. To this day the U.S. and other public health systems put no demands on individuals to be tested and none on those found HIV positive. The prevailing view is that to demand testing and partner notification would be to treat HIV-positive individuals like criminals... .The refusal to recognize that there were real ‘risk groups’ meant that public health and educational resources were spread thinly.. .a more aggressive public health response at the very start of the epidemic might have saved countless lives....

Individual liberty, privacy, free speech, and free choice are cherished values in any democratic society but they are sometimes invoked to obstruct social policies that favor universal health care, social welfare, and equal opportunity. Until all people, and women and children in particular, share equal rights in social and sexual citizenship, an AIDS program built exclusively on individual and private rights cannot represent the needs of all groups.

EVOLUTION OF CUBA’S AIDS POLICIES

While quarantine is the best-known aspect of Cuba’s AIDS program interna­tionally, it is in fact only one element of a policy that is simply part of Cuba’s over­all health system. In addition, Cuba’s AIDS policies have developed and evolved considerably over time. The goals have been similar to Cuba’s public health objec­tives during the dengue epidemic: identifying and providing medical care to those affected by the disease, and preventing its spread. In 1983 Cuba established a National Multidisciplinary Commission to advise the Ministry of Public Health on AIDS. Its initial step was to ban imported blood derivatives. By producing its own less efficient but safer blood derivatives, Cuba was able to protect transfusion recip­ients and in particular hemophiliacs—in 1989 only 4 out of 500 hemophiliacs in Cuba were HIV positive)

In 1985 when tests to diagnose HIV became available, a program of massive testing began. Thorough screening of all blood donors was the first step. In 1987 Cuban health officials announced that 1.1 million tests had been carried out, includ­ing every Cuban who had been out of the country between 1975 and 1986 (includ­ing soldiers, students, participants in cultural exchanges, diplomats, and foreign aid workers) and in particular Cubans who had served in Africa, as well as 23,000 preg­nant women. State agencies and neighborhood block organizations (CDRs) com­piled a census of all who had traveled outside the country, approximately 380,000 people, to identify them for testing. Plans were in the works to extend testing to everybody who entered a hospital or a physician’s office.

By the middle of 1988, the Cuban health ministry reported that close to one-­third of Cuba’s sexually active population and 20 percent of the entire population had been tested, uncovering a total of 230 seropositive persons (including the 147 reported in 1987). This program involved mandatory testing of 103,500 residents of Havana’s port area, only two of whom were found to be infected with HIV. In late 1988 Cuban health officials said that testing was being done on all patients admitted to hospitals, on all Cubans returning from abroad, and on all Cubans likely to have contact with foreigners because of their residence or work.

In 1992 the director of Cuba’s Institute for Tropical Medicine (which coordi­nates the AIDS program) listed sexual partners of persons testing positive for HIV, blood donors, hospital patients, pregnant women, tourism employees, merchant sea­men, and persons who return from abroad as those receiving routine testing for HIV. Homosexuals as a group have never been identified or singled Out for testing.

“QUARANTINE”

Since it is probably the most controversial aspect of Cuba’s AIDS policies, the quarantine system and its evolution over time are worth describing in detail. Beginning in 1986, persons found to be HIV-positive were sent to a sanitarium out­side Havana. Initially, the sanitarium was run by the military for returning soldiers from Africa, but in 1987, as the infection was found among more and more civilians, authority was transferred to the Ministry of Public Health. It was only during the first months that the sanitarium maintained an actual quarantine: patients could not leave the facility at all, although some visits were allowed. One resident told an inter­viewer in 1989 that “at the beginning we found ourselves almost totally isolated from society because the visits from relatives were restricted, because the means of trans­mission were not completely known. This isolation lasted a few months, and a system of passes and structured leaves was established and perfected over time.” After three months, the “quarantine” was modified to allow patients to leave on overnight passes with a chaperone approximately once a month. Terry explained in 1987 that “the interned Cubans are allowed home visits.. .but are warned that if they have sexual rela­tions, they need to protect their partners.” He added: “If his wife wants to have sex without that protection, it is her problem.”

It is clear that the quarantine system was never directed particularly against homosexuals per Se. Both Leiner and Lumsden argue, however, that there was discrimi­nation against homosexuals within the sanitarium in its early days. Lumsden writes that

 

gay internees.. .were subject to discriminatory policies within the Havana sanatorium. They initially lived in segregated quarters and were subject to greater restrictions than other residents with respect to the external passes that allowed them to make brief visits outside the sanatorium. They had to wait longer for such passes and were sub­ject to greater supervision by the nursing staff, who chaperoned them to ensure that they had no opportunity to infect others.

 

Scheper-Hughes attributes the segregation of homosexual residents to “conflicts [which] arose between these new arrivals and the defensively homophobic soldier patients,” and says that it was protests by these new residents that led to the first reforms in the system and the eventual transfer of authority from the Ministry of Defense to the Ministry of Public Health.

The first U.S. visitors to the sanitarium were a group of health professionals from Columbia University in late 1988. Sanitarium physical conditions were “pleasant,” they reported, and residents confirmed in interviews that “they maintained their original salary, they could go to the movies in town occasionally, could go home on weekends accompanied by a chaperon.” Married couples could live together and were also allowed unchaperoned excursions away from the sanitarium. Their uninfected children remained outside the sanitarium.

Addressing the U.S. visitors’ concerns about the “ethics” of mandatory testing and quarantine, Cuban health officials told them that “no coercion was necessary” for testing “since eventually all Cubans come into contact with the medical system in the workplace, at school, or during treatment for disease... .Informed consent for such testing was deemed unnecessary.” According to Vice Minister of Health, Hector Terry, “Physicians undertake the tests that they consider crucial. It is not for patients to make such determinations.” Swanson, Gill, Wald, and co-workers con­firm that:

 

Routine screening for a number of health concerns is widely accepted by the pop­ulation as an ongoing part of the public health program that reaches the entire population... .Support for HIV screening, as well as screening for other health con­cerns, is buttressed by strong social pressure, whether at work or elsewhere in the community, and has been widely accepted. Most persons who are in a priority-risk category passively accept testing as a routine part of their regular blood testing.

 

However, “documented reports show that the wishes of individuals who have refused when asked to submit to a test at the workplace or in the community have been respected.” Santana, Faas, and Wald wrote that during the general screening con­ducted in municipalities, significant numbers of individuals (130 in Old Havana and nearly 3,000 in Sancti Spiritus) refused to be tested.

 

They are not forced to provide a blood sample, but they are counseled about safe behavior on the assumption that they may be seropositive. However, it is clear that pressure from peers, neighbors, co-workers, and health officials is very strong, and many who would have preferred not to be tested have, nevertheless, agreed to it.

 

Terry also informed visiting U.S. health professionals that:

 

If people refused to enter the sanatorium, every effort was made to convince them of their obligation to do so and of their need for medical supervision. Friends, family, and neighbors were enlisted to help with the effort. Offered an opportunity to acknowl­edge that coercion was necessary at times, Dr. Terry demurred, noting that one woman had adamantly refused to enter the quarantine and that he had chosen not to invoke sanctions.

 

The authors noted that this information conflicted with exiles’ accounts (which they said could not be confirmed by human rights organizations) of physical coercion and concluded that only further study could determine the truth of the level of coercion involved. The authors also point out that Cuban officials “told us of a constant search for less harsh alternatives—such as permitting children to reside with their parents, allowing family members to assume responsibility for surveillance in some instances, and building new facilities more accessible from other parts of the country.”

In February of 1989, New Scientist magazine reported on Cuba’s sanitarium, not­ing that it was “surrounded by high wire fences. ..to dissuade inmates from leaving,” but that residents “are allowed out to local shops, although they must be accompanied by a sanitarium attendant, and are given five-day passes to stay with their families, again with a chaperone. But they must sign a promise to abstain from sexual rela­tions.” (Hector Terry confirmed the chaperone system to another U.S. visitor but wryly noted that “the technicians do not accompany them into the bedroom.” Perez-Stable noted that “at least one woman has been documented to seroconvert follow­ing weekend visits by her quarantined husband.” Santana, Faas, and Wald write that “chaperones cannot prevent behavior leading to new infections, but have a strong inhibiting effect on the resident.”) Housing was provided for married and for gay couples. The magazine quoted the director of Cuba’s AIDS testing program as saying: “Anyone in Cuba found to be HIV positive is asked to leave their job and home and is sent to the sanitarium. We send doctors and nurses to convince these people it is better to go. We create the conditions in which they will want to go. But no one puts a straitjacket or handcuffs on them.”Santana, Faas, and Wald documented one case where a seropositive woman refused to enter the sanitarium: “In that case, a woman with small children remained at home, closely monitored by the medical staff.”

After Dr. Jorge Perez took over administration of the sanitarium in early 1989, he initiated further reforms. He tore down the wall and barbed wire surrounding the sanitarium and began a series of measures aimed at integrating residents into the com­munity rather than isolating them. By September of 1989, residents—including doctors—were permitted to practice their professions inside the sanitarium. A visi­tor in late 1991 noted that among the staff of the sanitarium were five doctors, eight nurses, and four medical students who were all HIV-positive, and quoted Perez as say­ing that “this makes the level of trust very deep with other patients.”

Also in 1989, officials introduced a system to evaluate residents after six months in the sanitarium, allowing those judged responsible to leave the sanitar­ium without a chaperone. Those who left without permission were subject to a 50-peso fine by Cuban law. Knowingly infecting another could be punished with imprisonment. In 1991 Terry announced that some residents were being permit­ted to work outside the sanitarium, returning to the complex only to sleep. He stated that, “As time goes by the restrictions could become more flexible, but it will all depend on how responsible each patient proves to be.”

New facilities were built in central and eastern Cuba to allow patients to be interned closer to their homes: in 1991 there were five sanitaria; in 1992, there was one in each of Cuba’s 14 provinces.’ In a speech at the University of California, Berkeley, in late 1992, Perez told listeners that residents could leave the sanitarium essentially whenever they wanted. “There are no machine guns and guards,” he said. By 1993 the system of “quarantine” had been modified so that after a six-month pro­bationary period, residents were evaluated by a team of health professionals. Those judged to show adequate understanding of the need and the way to prevent transmis­sion of the disease were allowed to spend weekends and some weeknights away from the facility. Approximately 80 percent of the residents who had been there over six months were in this “guaranteed” category.

Since 1993, ambulatory care rather than mandatory sanitarium residence has been the primary strategy of Cuba’s AIDS program. Since the new policy was approved in the spring of 1993, family doctors have been educated about AIDS, and arrangements made for providing care in the home community. In January of 1994, the policy was implemented, and since then, “the sanitaria have operated as a geo­graphically based network of ambulatory care centers as planned. This policy provides initial education and continuing ambulatory care in a person’s home community by the neighborhood doctor and nurse.” Persons diagnosed as HIV-positive are initially admitted to a sanitarium and for a period of six months provided with treatment and education about the disease and methods for preventing its spread. After the six-month residence, patients are assessed by a team of health-care professionals, and most are given the option of ambulatory care in their communities. A conflict between the rights of the individual and the rights of the community (to be protected from the disease) is resolved in favor of the community in the case of those who are judged to be unwilling or incapable of engaging in responsible behavior to prevent the spread of the disease: they are obliged to remain in the sanitarium.

Interestingly, however, the majority of those given the option to leave have decided to remain. In Havana’s Santiago de las Vegas’ sanitarium, 75 percent of the 300 residents have been given the option, but only 68 had chosen to leave by late 1994. (In the country as a whole, 136 of the 1,077 HIV-positive citizens had chosen to receive ambulatory care.) By April 1995 170 had chosen the outpatient plan; by November, 184.~~ Residents cited the benefits of sanitarium residence including spe­cial diets, comfortable living conditions, and acceptance by the community as advan­tages of remaining there. One homosexual resident told an interviewer that “there is less repression of gays in Los Cocos [the sanitarium] than anywhere else in Havana.” Foreign visitors to the sanitaria have emphasized the comfort and home­like atmosphere there.’

It is also interesting to note that few Cubans have objected to Cuba’s approach to AIDS. In a generally unfavorable assessment of Cuba’s AIDS policies, Eliseo Perez-Stable, a physician of internal medicine, acknowledges that “although I discussed the HIV quarantine policy with other health authorities, family members, friends, and many regular working citizens, I detected not a hint of disagreement. I found this atti­tude impressive given the spectrum of public opinion on many issues voiced by the Cuban people.” Lumsden writes:

 

Some gay critics abroad interpreted the quarantine as further evidence of Cuba’s repressive discrimination against homosexuals. Yet in Cuba it was not perceived as either unusual or discriminatory. The program seems to have been supported from the outset by the majority of the Cuban population, including a majority of homosexuals, whose experience with Cuba’s health system has led them to place enormous trust in the country’s medical policies.’

RESEARCH AND DEVELOPMENT

Cuba has also devoted its scientific and technical—and as a result, considerable financial—resources toward the battle against AIDS. Cuban health officials estimate HIV-related expenses as approximately $15 to $20 million per year, or one percent of Cuba’s health budget. Cut off from collaboration with U.S.-based scientists and tech­nologies and from medications produced in the United States or by U.S. companies, Cuba relies on importing from afar and developing its own products. During the first year of HIV screening (1986), Cuba spent approximately $3 million importing equip­ment, but by 1987 the island had developed its own serologic test, reducing the cost substantially. In 1991 there were 45 laboratories on the island that could perform the test, and by 1993 there were 52 such laboratories. While some critics have questioned the reliability of the Cuban test, the accuracy of the testing system is enhanced by using a combination of the ELISA and the Western blot tests. A study conducted in collab­oration with the Oswaldo Cruz Foundation in Brazil and Sweden’s Ministry of Health confirmed the accuracy of the Cuban system. To increase testing among those wish­ing anonymity the country has also initiated a test-by-mail program whereby people send a drop of blood to a state-run laboratory and receive the results by mail.

Nancy Scheper-Hughes described the care and treatment of HIV-positive resi­dents in the sanitarium in 1993 in a very positive light:

 

All residents are treated with individually tailored regimens including interferons, transfer factor, and low-dose zidovudine. Those who do not respond well or who pre­fer alternative medicines are offered one of several antiviral herbal medicines cur­rently being tested at the sanitarium. A small infirmary handles patients with AIDS-related illnesses but the very sick are transferred to the Medical Institute for Tropical Medicine in Havana, where they are cared for with patients suffering from other seri­ous communicable diseases. Exercise and a diet rich in calories (5,000 kcal daily) and protein are integral parts of the regimen—indeed sanitarium residents are better fed than the average Cuban worker and each one costs the Cuban state about $15,000 a year.

 

Patients who become ill with AIDS also receive free hospital care as well as AZT and other medications at an estimated cost of $7,000 per patient per year. (Leiner notes in comparison that no facilities in Puerto Rico offered AZT since “if we give it to one, we should give it to everybody, and that would consume the [AIDS] Institute’s whole budget.” 110) Cuban researchers have also achieved promising results in a study using recombinant interferon alpha to stow disease progression in asymptomatic HIV carriers.”

Cuba has also been at the forefront of international efforts to develop a vaccine against AIDS. In 1995 Cuba announced plans to begin testing a genetically engi­neered vaccine on chimpanzees.” In June of 1996, Dr. Jorge Perez announced that animal trials had been “promising,” and in December 1996, 24 Cuban scientists car­ried out the first human trials on themselves.”

NEUROPATHY

The U.S. media and policy-makers were ostensibly less concerned for the well-being of the Cuban people when a mysterious epidemic of optic and peripheral neu­ropathy struck the island in 1991, affecting 50,862 people by January 1994—about 50 times more than the numbers affected by HIV.” While many medical professionals were quick to point out a relationship between U.S. policy and the outbreak, neither the U.S. role nor the Cuban success in coping with the neuropathy epidemic has attracted much U.S. media attention. This is in part because this disease does not fit into any ready-made U.S. categories about Cuba, like the “human rights violation” category.”

         In fact, Cuba’s response to the neuropathy epidemic was similar to its response to dengue and AIDS. By the end of 1992, 472 cases of optic and peripheral neuropa­thy had been diagnosed, and in early 1993—with 3,000 to 4,000 new cases appearing every week—the Cuban government launched a full-fledged effort to test for and study the disease. The Civil Defense for Disaster Relief, the Ministry of Public Health, and the Cuban Academy of Sciences coordinated a task force to research and test for the disease, mobilizing 18,000 family doctors; by May of 1993, 45,584 cases had been uncovered. During April and May, the government began a program of vitamin dis­tribution to the entire population of the island, and beginning in June, the number of new cases started to decrease dramatically. By the end of the year, the epidemic was essentially over.”

         The disease appeared first in the western, tobacco-growing province of Pinar del Rio, primarily in rural areas, among adult men between 25 and 65. Most were users of both tobacco and alcohol. This province had the highest incidence of cases overall (1,332.8 per 100,000), but as the disease spread to other provinces and to urban areas, it also spread to adult women. In the end women were more affected than men: of the total of 50,862 cases, the national cumulative incidence was 566.7 per 100,000 women, and 368.5 per 100,000 men. As of June 1993, only 57 children under 14 years of age had been diagnosed with the disease; 81 percent of these were between the ages of 10 and 14.i18 Pregnant women and young children—all of whom receive extra food through the ration—were rarely among those affected.”

        As in the cases of dengue and AIDS, Cuba’s response to the neuropathy epi­demic was characterized by a generous commitment of resources for identifying, studying, and tracking the disease, curing those afflicted by it, and preventing further cases once its nature was illuminated. Vitamin deficiencies, especially of B vitamins, were identified early in 1993 as an important risk factor, even while the precise etiol­ogy of the disease remained unknown. The government obtained materials for the manufacture of vitamin supplements to include 2.5 mg thiamine, 1.6 mg riboflavin, 20 mg niacin, 2 mg B6, 6 pg B12, 250 pg folate, and 2500 IU retinol, with half-dosages for children. These were distributed through family doctors to every citizen in Pinar del Rio in March and to the rest of the country in April and May. This distribution of vitamin supplements has continued on a monthly basis through the late 1990s. Most of those affected responded positively to the vitamin treatment, and there were no fatalities. Once the supplement program began, the number of new cases dropped sharply.’

            The case of neuropathy illustrates several interesting aspects of the relationship of health to politics. First, the epidemic was triggered by nutritional deficiencies and curtailed by government distribution of vitamins. As Dr. Gustavo Roman, who studied the epidemic for the WHO, pointed out, epidemics of this sort have historical­ly occurred in the context of extreme deprivation caused by war. In Cuba, how­ever, the deprivation was due to an economic crisis that had direct political causes in the collapse of Cuba’s Soviet-bloc trading partners and the tightened U.S. blockade of the country. “I found profound injustice in the occurrence of this huge epidemic of nutritional cause in a population not at war. Although the U.S. economic embargo against Cuba was not the primary cause of this epidemic, it certainly contributed to its development, complicated its investigation and treatment, and continues to ham­per its prevention." A joint Cuba-U.S. study that compared the epidemic to a sim­ilar outbreak a century ago in Cuba—which also occurred during a U.S. blockade of the island, during the Spanish-Cuban-American war—concluded: “Although we do not believe that the U.S. embargo is the only cause of the epidemic, we concur with the assessment of its significance made by Kuntz: that ‘it is the only one factor that was deliberately devised and is the only one that could easily be reversed.”

Roman summarized the direct relationship of the embargo to the epidemic as follows:

 

Feed and grains, including soybean meal for human protein supplementation, must be imported from places as distant as China, with resulting higher cost; bibliographic searches are almost impossible since Cuba cannot use the National Library of Medicine’s MEDLARS system; mail, telephone, and fax transmissions are unreliable; books, scientific journals, and information on science and technology are scant and outdated; and laboratory equipment, reagents, and materials for vitamin production are all covered by the embargo and can be purchased only at excessively high prices.

 

Adds Richard Garfield, professor at Columbia University:

 

The recent epidemic in Cuba.. .is not an incidental result of the breakdown of a weak government in a poor country but the intentional result of political measures taken by the United States.. ..In 1992, the U.S. embargo was extended to prohibit Cuba from purchasing foods or medicines from U.S. firms and their subsidiaries abroad and to limit such sales from other countries. This extension of the embargo is a major contributing cause of the Cuban people’s miseries. Many food imports were cut off; others became far more expensive. Because of the embargo, Cuba spends approxi­mately 30 percent more for the medicines it purchases in the international market than it would if those medicines were purchased in the United States, and many modern medicines, produced only under U.S. patents, are unavailable for purchase at any price. The vitamins that were used as the initial intervention in the epidemic of peripheral neuropathy cost Cuba $151,000; they would have cost $56,000 and would have been available far more rapidly if they could have been purchased in Miami.

 

The Cuban government’s response to the economic crisis has been to increase rather than decrease its protection of vulnerable sectors. Thus, pregnant women, chil­dren, and the elderly were all able to rely on nutritional supplements and were less affected by the epidemic. Neuropathy struck primarily healthy adults—that is, the strongest sector of the population—because they had not been targeted for protection. One health professional who studies the Cuban situation asked, “How many places do you know where the strongest, the biggest, the male population will give up what it has for the weaker population?”

HEALTH IN THE “SPECIAL PERIOD”

Economic crisis struck Cuba with the fall of the Soviet bloc in 1989. Cuba was very much part of the “old world order” and was dramatically affected by its replacement with a “new world order.” In the context of U.S. hostility to the 1959 revolution, Cuba turned to a close alliance with the Soviet Union, and Cuba’s economic development, especially from 1970 on, followed models advised and promoted by the Soviets. In some ways the relationship paralleled classic dependency: Cuba produced sugar for the Soviets and received manufactured goods in return. But unlike capitalist colonial or neocolonial powers, the Soviet Union was not seeking a profit from its dependency. The Soviets paid higher than world market prices for Cuban sugar—what they referred to as a “fair price” for political and strategic reasons. Thus, capital and resources flowed from the Soviet Union to Cuba, rather than the reverse, as is typical for capitalist metropole-colony relations. The impact of the U.S. economic blockade imposed in 1961 was mitigated by Soviet trade and aid.

Although Cuba benefited economically from its relationship with the Soviets, there were economic drawbacks too, especially in the long term. The island remained dependent on the production of a single primary export: sugar. Fully 70 percent of Cuba’s trade was with the U.S.S.R., and 85 percent was with the Soviet bloc. Cuba was heavily dependent on imported petroleum products for its agriculture and industry, on imported manufactured products, and even on imported food.

When the Soviet bloc began to disintegrate, Cuba’s economy entered a crisis. Cuba lost 85 percent of its foreign trade; it lost the ability to import the petroleum products needed to maintain, not to mention build and diversify, its agriculture and industry. Factories were closed, and sugar production collapsed. Cars and buses disap­peared from the streets, electricity vanished from people’s homes and food from their tables. The impact of the U.S. economic blockade had been mitigated by Cuba’s ties with the Soviet bloc; suddenly the effects of the blockade were felt with full force. In 1991, the Cuban government declared a “special period in time of peace” and began to impose emergency economic measures. And in 1992, the U.S. economic blockade was strengthened by the Torricelli Bill, which explicitly extended the embargo to foods and medicines.

This prohibition has had direct consequences for the Cuban health system. One study summarized the effects:

 

Some essential medicines and supplies are produced only in the United States and thus can no longer be purchased. These include the only effective treatment for pedi­atric leukemia, x-ray film for breast cancer detection, U.S.-made replacement parts for European-made respirators, and Spanish-language medical books from a firm recently bought by a United States conglomerate. Most medical products are also produced in other countries but cost more and require 50-400 percent higher shipping charges (estimated total of $4-S million extra) than required for the same goods purchased in the United States. Production of the 24 most common pharmaceutical products pro­duced in Cuba with imported primary materials is estimated to cost an additional $1 million per year due to the embargo. An estimated $181,000 was spent to transport vitamins to Cuba during the optic neuropathy epidemic of 1992-93; the cost would have been approximately $56,000 had they come from the United States. In all, the Ministry of Foreign Trade estimates excess costs to the health system at $45 million per year.

 

However, because of the character of Cuba’s social and economic system, eco­nomic crisis there had very different kinds of impacts than have comparable crises elsewhere in Latin America. Since the state controls the economy, it has been able to distribute the impact of the crisis equitably throughout the society, so that poten­tially vulnerable sectors have not been disproportionately affected. Overall, Cuba’s health indicators have remained very strong despite six years of economic crisis. Key indicators, such as infant mortality, have continued to decline. In 1989, Cuba’s infant mortality rate was 11/1000 and by 1995 it was 9/1000—roughly the same rate as that currently found in the United States.

Cuban officials note proudly that not a single school nor hospital has been closed, and that rationing has ensured that the population has equal access to what scarce food and products have continued to be available. In a capitalist economic sys­tem falling supply of basic goods would lead to rising prices, a sort of market rationing which grants access to those with wealth and deprives the poor. In Cuba, the state rations according to need. Milk, for example, was removed from the parallel marker when supplies fell, and is available only through the ration card or libreta to children under seven, to the elderly, and to those suffering from certain illnesses.’

At the same time, Cuba has been undergoing a process of economic opening, which in some ways seems completely at odds with the redistributive economic logic of the country. In 1993, the dollar was legalized, and several government-owned chains of dollar stores were opened to draw hard currency away from the black market.’’ The government has encouraged foreign investment and tourism as means of attracting much-needed capital to the country. In 1994 “free” farmers’ markets (conducted in pesos) were opened, where prices are governed by supply and demand. In 1995 many new forms of self-employment became legal. Cuban economists explain and defend these measures as necessary to revive production and help the country survive in the new world order. They emphasize that the market will be kept under strict limits, and that key sectors like health and education will never be subject to market forces. Nevertheless, the economic reforms, while indeed bringing in much-needed capital and increasing production, have also introduced a level of inequality unknown since the revolution. Cubans with access to dollars, either through relatives living abroad or through links (both legal and illegal) with the tourist and foreign investment sectors, have access to food, products, and entertainment ordinary Cubans only dream of.

The crisis—and the contradictory measures taken to relieve it—have inevitably had a substantial impact on public health and health-care delivery in Cuba. Many basic food items are scarce or available only for dollars; food available through the libreta covers only about half the month’s needs. Especially during the difficult years of 1993-94—before the economic recovery began—hunger was the norm. Still, hunger in Cuba meant weight loss for virtually the entire adult population rather than mal­nutrition among children and the poor. In fact, as noted above, it was healthy adults who were the main victims of neuropathy caused in part by undernutrition.

In strictly medical terms, some U.S. analysts have argued that decreased food consumption had its benefits since obesity was a serious health problem prior to the Special Period. However, Cuban health officials are more concerned about nutritional deficiencies than obesity. In addition to the neuropathy epidemic, the consequences of inadequate food supply have been seen in increases in the incidence of low birth weight (which rose from a low point of 7.6 percent in 1990 to 9.0 percent in 1993), the number of women underweight at the beginning of pregnancy (8.7 percent in 1900, 10.0 percent in 1993), and in the frequency of insufficient weight gain during pregnancy (the percentage of women affected rose from 5.5 in 1990 to 6.1 in 1993).

It should be noted, however, that these rates are still extremely low by inter­national standards, and they have not translated into increased infant and child mortality; they have provoked a concerted government attempt to counteract the trend. In 1994 a National Low Birth Weight Program was initiated to attack the problem on several fronts. The program seeks: to carry out studies identifying pre­conceptional and obstetrical risk factors for low birth weight; to work with the National Mother-Infant Department to increase the number and utilization of maternal homes” which provide four meals a day and a residential option to preg­nant women’; to make meals for pregnant women available in hospitals, work­places, and agricultural cooperatives; to work with UNICEF to provide multivitamin and iron tablets for women during pregnancy and for four months after delivery.’

Despite such initiatives, the impact of the economic crisis on health has not been insignificant. Medications, hospital supplies, and equipment, ranging from the most basic—sheets, pens, and aspirin—to the most advanced, are all in desperately short supply. Infectious disease and parasite morbidity and mortality rates have risen since the 1980s, due primarily to material scarcities affecting public sanitation. In particular, there has been little chlorine available for water purification. The portion of the population with access to chlorinated water declined from 98 percent in 1988 to 26 percent in 1994. Tuberculosis and typhoid fever rates have risen slightly, as has mortality from diarrheal diseases. Nevertheless, these figures remain quite low by international standards: infectious and parasitic diseases accounted for 2 percent of deaths in 1993 while 74 percent of deaths were due to chronic and degenerative diseases and accidents.’

Lack of food has also seriously affected the health of the population. Some of the measures Cuba has taken to increase food production and importation are inevitably at odds with efforts to guarantee equity in food distribution. Fidel Castro described these contradictions in April of 1996:

 

Measures were adopted, such as the farmers’ markets, to give impetus to food pro­duction, to open up the possibility of being able to buy some things which were impossible to obtain, given the situation we were in, although clearly, they weren’t the methods we used before, when we could distribute pork, chicken, eggs, milk, etc., at minimum prices, which was a better way... .Nevertheless, we had to find a way of making that [excess] money circulate a little, to collect a little money and, moreover, many people were absolutely convinced that the farmers’ markets were a solution, and since people with a lot of money in their pockets, who didn’t have anything to spend it on, were saying, ‘It’s better to have somebody supplying something, never mind the price.

 

However, making imported food available in dollars meant that while the overall sup­ply increased, inequality in access also increased. At the same time, though, the gov­ernment strictly limited the free market in food in the interests of equity.

 

One of the sacred things that we had to defend was the ration system still available to the population, to guarantee that [people receive] minimum amounts of garden and root vegetables, and other food products where possible [even though] a significant proportion are imported foodstuffs. This meant guaranteeing rice [and] guaranteeing specific quantities of beans...

 

With respect to the availability of medical services, one analyst summarized the situation this way:

 

The spectrum of medical services available has been maintained, although quantita­tively the numbers of services provided have diminished. The population is affected by the intermittent supply of medications, the absence of some medications, limits in the diagnostic tests available because of lack of supplies, decreasing quality of hospi­tal services, in particular in the area of food and hygienic conditions for patients in the hospital, and even by difficulties in transportation to get access to medical ser­vices that are not available in the community.

 

Several factors have contributed to the ability of the health sector to survive the economic crisis. In addition to trying to distribute the impact of the crisis equitably and to protect vulnerable sectors, the Cuban government has attempted to take advantage of the strengths of its system. One of the greatest of these strengths is the human capital Cuba has built up over the past 40 years. In the area of health, despite material scarcities, Cuba has an enormous number of trained professionals. In the mid-1980s the country began to implement the family doctor program in an effort to move primary health care out of hospitals and clinics and into the neighborhood. One of the program’s goals was to shrink health sector costs by increasing preventive and diagnostic care and reducing the perceived over-use of hospitals and clinics for prob­lems treatable outside these institutions. Family doctors live in the immediate com­munity they serve and are responsible for the health of the community in both pre­ventive and curative terms. A doctor and nurse team cares for approximately 100 families. The nationwide implementation of the family doctor program has been a sig­nificant part of Cuba’s attempt to carry out an “adjustment with equity.” Cuba now has approximately one doctor for every 200 inhabitants—one of the highest rates in the world.

In addition, the Cuban government has taken advantage of the country’s “com­parative advantage” in advanced medical technology with low labor costs to produce biotechnological and pharmaceutical products for export. The government also fos­ters “medical tourism,” offering low-cost medical services to foreigners. Profits from these exports have contributed to maintaining Cuba’s health sector. Some hard cur­rency earned in other sectors is also funneled into health.’

A delegation from the American Public Health Association described the extraordinary commitment of health professionals in Cuba who continue to provide necessary services under conditions of extreme scarcity:

 

Doctors in the major children’s hospital meet each morning to assess patients’ needs and resources available for that day. As a result, the use of x-rays (the results of which were normal in 99 percent of cases) has been reduced by 75 percent... .The same chil­dren’s hospital administrators report spending a considerable amount of time on the telephone calling colleagues in other countries to urgently request enough pills to get a particular patient through the week.. . . Medical personnel have increased home vis­its and are releasing patients from hospitals for follow-up care in the home. Health providers are increasingly using herbal remedies, acupuncture, and other non-Western procedures. However, in spite of their greatest efforts, the health workers are stretched to the limit. They are working long hours in highly stressful circumstances. Physicians and nurses, forced to severely ration resources, must count every pill and measure every drop of medicine they use. Difficult decisions must be made concern­ing which patients get diagnostic tests or medicines. So far, the health providers have been able to maintain health services. However, their ability to further ration scarce resources and resort to alternative procedures is extremely limited.

 

On a visit to the Diez de Octubre hospital in May 1996, doctors described to a visiting delegation some of the same conditions and went on to detail experiments in their Pain Clinic with therapies ranging from acupuncture to mud. One delegation member asked, “How can you keep such a spirit of dedication that keeps you working when you could earn so much more by leaving the health sector and working in tourism?” The doctor smiled wearily. “You’re asking that question in the wrong place,” he told her. “If you want to know how we build our spirit of dedication, you have to go back to the day—care centers.

Just as important as cost-reduction measures, however, has been the over­whelming governmental commitment to the health sector. All of the factors described previously show how the government was able to maintain good health outcomes with less input of resources. However, when the epidemic of neuropathy hit the island, it was clear that only a major commitment of resources (in the form of vitamin supplements) would stem the epidemic—and that commitment was immediately made.

LESSONS OF THE CUBAN CASE

The first lesson of the Cuban case is that equity in health care and outcome is achievable, even under conditions of material scarcity. Cuba has attained excellent health outcomes with comparatively low levels of resources, and has maintained a strong health profile in the midst of a severe economic crisis exacerbated by economic warfare and blockade.

The second lesson is that Cuba’s outcomes are possible because of a govern­mental commitment not only to health in the narrow sense but to social equality and social justice. Merely devoting resources to the health sector would not have achieved the same results. In Britain the health-care delivery system offers universal access, yet equity in health outcomes has not been achieved. In Cuba the commitment to equality and human development has allowed the country’s achievements in the area of health to withstand the most appalling material scarcities.

These first two lessons are hopeful ones. The third lesson is less encouraging. An inevitable conclusion for anybody studying the Cuban case is that the “New World Order” in general and U.S. policy toward Cuba in particular are unalterably opposed to the project of social justice and improved health Cuba has carried out over the past 40 years. As one U.S. policy-maker mused in 1959, “There are indica­tions that if the Cuban Revolution is successful, other countries in Latin America and perhaps elsewhere will use it as a model. We should decide if we wish to have the Cuban Revolution succeed." The decision was made within months of the revolution. In July of 1959, the director of the Office of Inter-American Regional Economic Affairs informed the State Department that “Castro’s Government is not the kind worth saving,” and a program to overturn it began.

United States officials were quite open about the fact that Cuban success in achieving economic independence and social justice would threaten U.S. profits not only in Cuba but also elsewhere in the hemisphere. The United States wished to avoid showing any “weakness” before Castro’s “provocations.” If the United States did not crush the Cuban revolution, continued one high-level U.S. official to another, this failure could:

give encouragement to communist-nationalist elements elsewhere in Latin America who are trying to advance programs similar to those of Castro. Such programs, if undertaken.. . [could expose] United States property owners to treatment similar to that being received in Cuba and. . . prejudic[e] the program of economic development espoused by the United States for Latin America which relies so heavily on private capital investment.’

The Cuban revolution’s redistributive policies threatened the explicitly stated U.S. goals of maintaining Cuban “receptivity to U.S. and free world capital” and safe­guarding “access by the United States to essential Cuban resources."

United States policy toward health in Cuba has explicitly aimed to deny and undermine the revolutionary government’s attempts to improve the health of the population.’’ Through economic blockade and sabotage, through chemical and bio­logical warfare, and through outright invasion and subversion, the United States has for 40 years pursued its goal of destroying the “threat of a good example” that Cuba’s successes in health and social justice provide. Development scholars have to a large extent echoed the U.S. position that the economic development model the United States supports for Latin America is the best answer to the region’s social problems. Many scholars deny the Cuban experience by simply leaving it out of their compara­tive studies. Some dismiss Cuba’s obvious successes by embedding them in discussions about “human rights”—narrowly defined as individual political freedoms. Those who do discuss Cuba often downplay or ignore the fact that the Cuban experiment has been carried out in the context of unremitting hostility and aggression from the United States, situated only 90 miles from Cuba’s shores. The U.S. travel ban and the distorted portrayal of Cuba in both popular and scholarly media ensure that the majority of North Americans do not learn that a poor, Third World country, gripped by economic crisis, and under constant attack from the most powerful nation in the world, is still able to achieve health standards higher than those in the capital of that powerful nation, Washington, D.C.’