AIDS: Is the Cuban strategy working?
By Karen Wald [This article is a response to a letter in GLW #215 from Ken Davis, criticising an article by Karen Wald in issue 214.] I wish I had time to answer individually and promptly all the people, like Ken Davis, who continue to attack Cuba's AIDS prevention and care program based on their misconceptions and/or personal biases. I also wish that such people would take more care to investigate thoroughly before stating as "fact" things they know little or nothing about. I don't know where Ken Davis is getting his information, but it certainly isn't from living in Cuba and working with the HIV+ education group GPSIDA, as I have been doing for many years. Ken attacks my article as "lacking integrity" because, he says, my analysis "obscures the key questions about the quarantine system" (sic), which he believes revolve around the issues of personal liberty of those infected. We have a fundamental conceptual difference that I think will not be resolved (among other reasons, because he is looking at AIDS as a social and political issue, where I look at it as a health issue). While I agree that the questions he raised are important, and should be answered each and every time it is apparent that people are still confused or misled about these issues, I disagree that they are the key questions. They are peripheral to
the key question: what method of dealing with the disease will save the most lives? (You have no rights at all when you are dead.) Ken Davis' letter is a political diatribe, a thinly disguised attack on Cuba's political system. As such, it is more a reflection of his political inclinations than a serious analysis of what works best in slowing the spread of the AIDS epidemic and providing optimal care to those who are infected.
Medical approach
Because I prefer a
medical and epidemiological approach rather than a political one when discussing a health issue where lives are at stake, I will quote medical people, primarily, in responding to some of Davis' points. The first is Dr. Ralph R. Frerichs, chairman of the Department of Epidemiology, University of California at Los Angeles, who wrote me after reading the same article Ken Davis responded to. Here are some excerpts from several of his email letters: "For some while I have been fascinated with the approach that Cuba has taken to the HIV/AIDS epidemic. Yet here in the United States, because of the tensions between America and Cuba, few are willing to recognize or even review the apparent successes of the Cuban program. Here at UCLA I specialize in problems of developing countries. Thus I view Cuba as an interesting example of what can be done to combat HIV/AIDS with scarce resources if the political will is there ... "My main concern at present is with the issues of widespread testing and normalization of HIV infection, a strategy that offers new hope for controlling the epidemic." He refers to Elinor Burkett's new book,
The Gravest Show on Earth, considering "especially poignant" a passage which reminds us that some "misguided activists" have, in Burkett's words, "helped sow a community ethic that demands that the
uninfected assume full responsibility for self-protection". (Interestingly, a concept that the World Health Organisation this year also began to oppose). He further quotes Burkett: "There is no social pressure on HIV-positive men [RRF: or women for that matter] to acknowledge their infections before engaging in sex, to keep their partners from risk. The message is not Do Not Harm [which is presumed to be the basic ethic of all doctors and medical personnel — KW]; it is Every Man for Himself.' Frerichs summarises, "And this is where we have come in a nation with extensive resources but a reluctance to address HIV as a viral infection rather than as a social problem". "Apparently Cuban health officials have been able to establish the public health message of 'Do Not Harm' in the minds of many HIV infected people. How is this best done is the question I would like answered." In another letter, Dr Frerichs commented: "... with the new drugs that are becoming available, it will be increasingly important to detect HIV infected persons early in the course of the disease. In the United States, about half of all AIDS patients were first detected by HIV antibody testing
one year prior to their AIDS diagnosis." He quotes the medical abstract in its entirety; I will cite only the objective and conclusions of the study: "Abstract: OBJECTIVE: To describe the location of, primary reason for, and time between the first positive HIV test and AIDS diagnosis in a sample of persons with newly diagnosed AIDS ... "CONCLUSION: Most persons with AIDS were tested relatively late in their course of HIV infection, in acute health-care settings, and because of illness. Not knowing one's serostatus precludes early medical intervention and may increase transmission." Frerichs continues in his letter: "This means that half of all American AIDS patients were unaware of their infection for 7 to 9 years, preventing them from getting any early medical assistance and
permitting them to inadvertently pass the virus from one to another" (emphasis added). For me, as for any serious epidemiologist or medical person dealing with AIDS, these are the crucial issues determining the life or death of millions of persons throughout the world. Blissful ignorance that one is harbouring the disease not only prevents an HIV carrier from getting the kind of early attention that may prolong his or her life (in countries such as Cuba that do universally provide such care), but also means that the infected person continues to infect others. Ken Davis views Cuba's massive testing for HIV as an infringement on people's individual rights. Even aside from his misconceptions about how massive and how obligatory this testing is (no-one in Cuba can be obliged to take a blood test, although all blood donors know that all donations will be tested), he is the one who sidesteps the crucial issue: a person's right not to be unknowingly infected with a lethal virus.
Health care system
Frerichs suggests we should also look at the caring nature of the contact HIV-infected people have with their health care system. "In Cuba, you do not feature testing and counseling for an hour or less and then leave HIV infected persons on their own, as is often done in the West. Instead the Cubans have developed an extensive (and likely very expensive) support system that offers caring, assistance, education, and treatment." Frerichs asks: "What awaits an HIV infected person when he or she first learns of the infection in Australia?" Do they get the long-term, caring, attention that people in Cuba get? To Davis, and many others who believe the usually antagonistic reports circulated about Cuba, this question might seem irrelevant. Davis believes homosexuals and "sex workers" (a highly debatable term when applied to those relatively few women who choose to sell themselves sexually to affluent foreigners in the context of the struggle for survival that
all Cubans are engaged in right now) are horribly mistreated and discriminated against within the Cuban AIDS program. Nothing could be further from the truth.
All of the original members of the
non-governmental AIDS education/prevention group, GPSIDA — who have the most freedom to travel within and outside the country as part of their educational efforts — were gay, and most of the current members of the expanded group are gay, although they have added a number of women as well. If anything gave a boost to greater acceptance of homosexuality in Cuba, it was the caring and respectful treatment which gay men with AIDS have received in the AIDS sanatoriums after their own behaviour taught the less-conscious health workers and staff there (many of whom were knowingly coming in direct daily contact with gay men for the first time) that judgments based on sexual preference were simply inaccurate. The AIDS crisis prompted gay men with HIV to go public, in schools, community events, rock concerts and television, to alert others to the menace of the disease and the ways to avoid it. This year's World Health Organisation slogan for World AIDS Day was "Shared Rights and Responsibilities". Cuba had already adopted that concept in 1991, when the national slogan was "Share the Challenge" of AIDS. As far as the question of "discriminating" against "sex workers" when analysing whether a person is considered responsible enough to be allowed "carte blanche" — certainly. The criteria for determining whether AIDS education has been effective enough to consider a person "safe" to mingle socially with no surveillance is simple and to the point: is this person prepared to safeguard his/her own health and the health of others? It would be foolhardy to release back into the population a person who is likely to engage in unprotected sex with multiple partners on a daily basis. We aren't talking here about whether the Cuban government respects people's rights, but about
which rights, and
whose rights, should have priority in any society. Ken Davis, like many others who are not facing the immediate life-and-death issues of AIDS as health personnel are, or who at least are not looking at it in these terms, considers personal freedoms of people with AIDS to be above the community's interest in preserving the lives of all its members. No responsible health official in the world could adopt that stance. Is Cuba's program of preventing and controlling the spread of the disease effective? Davis disputes this (although I saw no data he offered to back up his contention). Frerichs suggests that the most convincing data can be found in the
Annual Incidence of AIDS, published for our region by the Pan American Health Organisation of the World Health Organisation. To put things in perspective, he sends us PAHO's Table 2 with the six-year time trend from 1989 to 1994 for four countries: Cuba, Dominican Republic, Puerto Rico (actually a territory) and the USA. The values are as shown, with 1994 underestimated in some due to delayed reporting. Frerichs offers the following comments in this regard: "The best comparison is with Puerto Rico, an island territory that has adhered to the control strategies advocated by Davis and his colleagues, and favored by many in the World Health Organization. With this 'loose' approach, Puerto Rico has gone from 459 per million in 1989 to 655 in 1993, and likely higher in 1994 when the final figures come out. "Thus the fundamental question that Davis needs to address is whether the 'free and open approach' (or what some of us might call neglectful) is worth an additional 647 new AIDS cases per million population per year (i.e., the 1993 Puerto Rican rate minus the 1993 Cuban rate)? "While he may think so, the many new AIDS cases among the island peoples of the Caribbean who suffer from the disease may wish that public health officials had been more supportive of
effective prevention infection."