[Marxism] How Cuba dealt with the AIDS epidemic

Louis Proyect 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 
women.

“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.

Universal Coverage

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 
infant mortality.

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 
quarantine policy.

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 
promiscuous.”

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.”

Rising Challenge

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 
epidemiologist.

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 
extramarital affairs.

The government distributes more than 100 million condoms a year. 
Every place with young customers, even pizzerias, is required to 
stock them.

“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 
antiretroviral drugs.

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 
anyone else.

However, it requires modern drugs and Cuba makes only the older, 
harsher ones. Only about 1,100 patients get new drugs, paid for by 
foreign donors.

“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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