[Marxism] How Cuba dealt with the AIDS epidemic
lnp3 at panix.com
Tue May 8 13:13:26 MDT 2012
NY Times May 7, 2012
A Regime’s Tight Grip on AIDS
By DONALD G. McNEIL Jr.
HAVANA — Yudelsy García O’Connor, the first baby known to have
been born with H.I.V. in Cuba, is not merely still alive. She is
vibrant, funny and, at age 25, recently divorced but hoping to
remarry and have children.
Her father died of AIDS when she was 10, her mother when she was
23. She was near death herself in her youth.
“I’m not afraid of death,” she said. “I know it could knock on my
door. It comes for everyone. But I take my medicine.”
Ms. García is alive thanks partly to lucky genes, and partly to
the intensity with which Cuba has attacked its AIDS epidemic.
Whatever debate may linger about the government’s harsh early
tactics — until 1993, everyone who tested positive for H.I.V. was
forced into quarantine — there is no question that they succeeded.
Cuba now has one of the world’s smallest epidemics, a mere 14,038
cases. Its infection rate is 0.1 percent, on par with Finland,
Singapore and Kazakhstan. That is one-sixth the rate of the United
States, one-twentieth of nearby Haiti.
The population of Cuba is only slightly larger than that of New
York City. In the three decades of the global AIDS epidemic,
78,763 New Yorkers have died of AIDS. Only 2,364 Cubans have.
Other elements have contributed to Cuba’s success: It has free
universal basic health care; it has stunningly high rates of
H.I.V. testing; it saturates its population with free condoms,
concentrating on high-risk groups like prostitutes; it gives its
teenagers graphic safe-sex education; it rigorously traces the
sexual contacts of each person who tests positive.
By contrast, the response in the United States — which records
50,000 new infections every year — seems feeble. Millions of poor
people never see a doctor. Testing is voluntary, and many patients
do not return for their results. Sex education is so politicized
that many schools teach nothing about protected sex; condoms are
expensive, and distribution of free ones is haphazard.
Cuba has succeeded even though it has the most genetically diverse
epidemic outside Africa. Almost all American cases are of one
strain, subtype B. Cuba has 21 different strains.
The genetic diversity is a legacy of its foreign aid. Since the
1960s, Cuba has sent abroad thousands of “internationalists” —
soldiers, doctors, teachers and engineers. Stationed all over
Africa, they brought back a wide array of strains. According to a
study in 2002, 11 of Cuba’s 21 strains are unknown elsewhere,
formed when two others mixed.
And Cuba’s success has come despite its being a sex tourism
destination for Europeans and Canadians.
While the police enforce laws against overt streetwalking, bars
and hotel lobbies in downtown Havana are filled with young women
known as jineteras — slang for “jockeys” — who approach
foreigners, asking if they would like to go for a drink, or
perhaps dancing, with the unspoken assumption that it will lead to
more. Even so, of the roughly 1,000 new infections diagnosed each
year, 81 percent are among men and very few among young unmarried
“Most of those who sleep with tourists know to use condoms,” said
Dr. Ribero Wong, an AIDS specialist here.
In a survey in 2009, 77 percent of all sex workers said they
regularly used condoms.
There are male jineteras for gay tourists too, of course, “but we
believe the main vector is within the people,” said Dr. Luis
Estruch Rancaño, deputy minister for public health. “Mainly, the
very promiscuous group in the homosexual community who have many
partners and don’t take precautions.”
One example is Carlos Emilio García, 50, a registered nurse who
lives and works at a former quarantine sanitarium outside Havana.
He had negative H.I.V. tests at his job every six months from 1990
to 1996, but became infected in 1997.
He admits to having had many partners; as he put it, “No, I don’t
know who my assassin is.”
Asked why a well-educated nurse would risk sex without a condom,
he waved his hands in the air and replied, “You know — because we
all do crazy things sometimes.”
The few Cuban women who are infected usually get the virus from
partners who are secretly bisexual, experts said.
“Homo-bisexual transmission” is its own category in Cuba;
socially, a man who occasionally has sex with other men is not
considered gay if he is a “top” — the penetrative partner,
explained Ramón Arango García, a fashion designer and educator at
the National AIDS and Sexually Transmitted Disease Prevention Center.
Heroin use, which drives epidemics in many countries, is virtually
nonexistent in Cuba, officials insist.
And since 1986, only 38 babies have been born with the virus. In
Cuba’s cradle-to-grave health care system, pregnant women get up
to 12 free prenatal checkups, during which they are tested for
H.I.V. at least twice.
Before antiretroviral drugs were available, H.I.V.-infected women
were offered abortions or, if they chose to deliver, Caesareans
and free infant formula to discourage breast-feeding and reduce
the risk of transmission. Now they get the drugs free.
As broken as it is economically, Cuba still points proudly to one
legacy of its 1959 revolution: Basic health care is universal and
free. Cuba has 535,000 health care workers (“We’re all either
doctors or baseball players,” one hospital microbiologist joked)
and each citizen is officially registered with a family doctor
nearby; if a patient skips a checkup, the doctor is expected to
find out why.
“I was trained to expect my patients to come to me,” said Dr.
Rafael Mazín, senior AIDS adviser for the Pan American Health
Organization in Washington, who is Mexican. “In Cuba, the doctor
comes to you.”
Cuba is tied with the United States in both life expectancy and
Dr. Jorge Pérez Ávila is Cuba’s Tony Fauci, its best-known AIDS
doctor. He is grandfatherly now, and clearly much loved by former
patients like Ms. García, but he has memories of helping his bus
driver father make gasoline bombs to throw at the police during
the Batista government. As a teenager he dropped out of school to
live in the mountains, teaching villagers to read under a literacy
program after Castro came to power.
He treated Ms. García’s parents on their deathbeds and heard her
father beg, “Do whatever it takes to help my daughter live.” (Her
father, who had been a soldier in Angola, was a truck driver. He
had nine girlfriends in different towns, five of whom he infected.)
Many medical authorities agree that Cuba had an early and
effective response to the epidemic. In his book, “AIDS:
Confessions to a Doctor,” published only in Spanish, Dr. Pérez
gave his account of the meeting that galvanized Cuba’s response.
In 1983, Fidel Castro visited the Pedro Kourí Institute, Cuba’s
top tropical disease hospital, to hear a presentation on malaria
and dengue fever.
As it ended, he suddenly asked the director, “Gustavo, what are
you doing to keep AIDS from entering Cuba?”
Dr. Gustavo Kourí, son of the institute’s founder, was caught off
guard, Dr. Pérez said, and stammered: “AIDS, comandante? AIDS? It
is a new disease. We don’t even know whether it’s produced by a
bacteria, a virus or a fungus. There isn’t much data on it, just
what’s been reported in the United States and a few cases in
Europe. It will take time to know how big it is.”
Mr. Castro replied: “I think it will be the epidemic of this
century. And it’s your responsibility, Gustavo, to stop it
becoming a major problem here.”
This was two years before any American president publicly uttered
the word “AIDS.” Asked how Mr. Castro could have been so
prescient, Dr. Pérez struggled to find the right word, then said:
“Castro has luz larga” — “big lights,” the Cuban slang for
automobile high beams. “He reads a lot. He sees far ahead.”
Dr. Pérez is simultaneously both a fan of the Castro government
and a bit of a cynic; on Dec. 1, he led a “Viva, Fidel!” cheer at
his hospital’s World AIDS Day. But he also mentioned that Mr.
Castro once praised him by saying: “Jorge, I’ve been reading your
mail. Your patients say very nice things about you.”
The medical establishment reacted quickly. The first step was to
throw out all imported blood — 20,000 units. That avoided the
devastation that the hemophiliac populations in the United States
and France suffered.
Doctors were sent to Brazil and France to study cases.
All of the country’s family doctors were ordered to watch for
infections that indicate AIDS like Kaposi’s sarcoma or
Pneumocystis carinii pneumonia.
Because there was no H.I.V. test yet, the first cases were found
late in the disease, leading doctors to think most patients died
within a year — an erroneous assumption that helped justify the
In 1986, blocked by the embargo from buying American test kits,
Cuba bought 750,000 French ones.
According to Dr. María Isela Lantero, AIDS chief at the Health
Ministry’s, Cuba’s 11 million citizens have been tested 43 million
times; last year, more than two million tests were done. That is
the equivalent of testing the sexually active population every
three years, though in reality the focus is on high-risk groups,
who are tested more often.
Cubans returning from abroad are routinely tested, as are pregnant
women, prisoners, soldiers, hospital patients, health workers and
anyone treated for venereal disease. So is anyone whose family
doctor suspects he or she is gay, a sex worker or otherwise at risk.
Haydee Martínez Obregón, 33, who has lived in the AIDS sanitarium
in Sancti Spíritus, in central Cuba, since she was 19, is an
example of that. (She lives there by choice, she said, because she
has no home outside.)
Asked how she learned she was infected, she said, “My family
doctor thought it was a good idea to test me because I was so
And how did he know that?
“My mother told him everything.”
Anonymous voluntary testing is also available at 700 clinics and
hospitals.Anyone who tests positive gets an appointment with an
epidemiology nurse, who asks for the names of everyone he or she
has ever slept with.
By law, answering is voluntary.
“If they say no, nothing happens,” Dr. Pérez said.
But pressure is clearly applied. A patient who says no to the
nurse gets an appointment with the doctor, then with a social
worker and then sometimes with a psychologist. Then a team of
H.I.V.-positive educators will make a home visit. So might the
local Committee for the Defense of the Revolution. Depending on
whom one asks, those committees are the defenders of Cuban
democracy, domestic spies or just state-sponsored Nosy Parkers.
Some still refuse. Arachu Castro, a professor of global health at
Harvard Medical School who often works in Cuba, described one
woman who absolutely insisted that she had never slept with anyone
but her husband, who was virus-free.
“We called her the Immaculate Infection,” she said.
There are other subtle pressures, Dr. Castro said. Socialist
education teaches Cubans to feel responsible for one another.
Also, most Cubans subsist partly on government rations and the
sick get extra food, and their lifesaving drugs, from the government.
Everyone who tests positive also must take a two-week course in
“living responsibly with H.I.V.”
With mandatory quarantine long gone and the virus now mostly in
gay and bisexual men, new infections are slowly but steadily
rising. They now approach 1,000 a year, “and we’re waiting for the
plateau,” said Dr. José Joanes Fiol, the Health Ministry’s chief
Today, condoms and sex education are the chief weapons.
Cuban society is the opposite of puritanical; scanty clothing is
routine, suggestive flirtation is common, and so are divorce and
The government distributes more than 100 million condoms a year.
Every place with young customers, even pizzerias, is required to
“The first ones we got were from China, and had butterflies and
penguins on the package,” Manuel Hernández Fernández, an AIDS
educator for 25 years, said with a snort. “We had to Cubanize them.”
Now one shows a man groping a naked breast; another has two men.
During a condom giveaway for World AIDS Day, women laughed as
volunteers — mostly gay men — dropped condoms into their cleavages.
“Just one?” one woman said. “What am I going to do with just one?”
Omairy Lorenzo, 18, a journalism student in Havana watching the
giveaway, said she had been shown how to put a condom on a model
penis at school when she was 12.
Her classmate Abel Lescaille, 20, said, “Sometimes they do so much
sex education that you get tired of it.”
Until recently, Cuban society and government policies were deeply
homophobic; in the revolution’s early days, gay men were sent to
labor camps. Fidel Castro now publicly says he regrets that action.
Now there is more acceptance.
At the same time, the government controls virtually all real
estate, and there are no gay bars or hotels. Cruising men often
have unsafe sex in abandoned buildings or parks where muggers lurk
and the police conduct raids, said Libán Molina, 41, a volunteer
at an AIDS prevention hot line.
Only about half of the 11,674 Cubans living with H.I.V. are now on
In theory, Cuba would be an ideal laboratory for “test and treat,”
the new protocol in which patients who test positive go on drugs
immediately to reduce by 95 percent their chance of infecting
However, it requires modern drugs and Cuba makes only the older,
harsher ones. Only about 1,100 patients get new drugs, paid for by
“We know about test-and-treat,” Dr. Pérez said. “We would do it,
if we could. But we need the funds.”
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