A Model for the Developing World By Edwin Krales In April 2003, Cuba hosted FORO 2003-"the second forum on HIV/AIDS and sexually transmitted diseases in Latin America and the Caribbean." This was a crucial conference. Except for Cuba (0.7%), the Caribbean has the 2nd highest rate of AIDS in the world (2.3%) after sub-Saharan Africa (9%). During the 6-day conference, 1483 delegates, worldwide, made dozens of presentations. There was no U.S. delegation, but there were U.S. presenters. I was in Havana delivering needed medical supplies. Since 1990, I have been a nutritionist with the U.S. HIV community. In 1993 I began collecting donated surplus medical supplies for Cuba. I presented a paper on HIV/AIDS and body composition using state of the art Bioelectrical Impedance Analysis technology (BIA). BIA measures body cell mass (BCM), water, fat and other compartments in your body. Loss of more than 46% of normal BCM is incompatible with life. A unique BIA measurement, the phase angle (PA), best indicates long- range survival potential in the HIV infected. PA measures "strength" of an individual's cell membranes by changes in electrical conductivity. Healthy cells have higher PA than sick cells. The conference was a success, in large part due to the sense of purpose that Cuba's HIV community always displays. My Cuban hosts were part of the conference organizing committee. They told me to prepare for some surprises. The 1st was that President Fidel Castro attended both the opening and closing plenaries. He did not make a five-minute welcoming speech and leave. He participated in both events from start to finish because of the importance of the subject. For the world,s delegates, Castro's informed participation-reinforced Cuba's centrality in the worldwide fight against AIDS. Another surprise was the participation of the World Bank. What was Ms. Debrework Zewdie, the Caribbean regional representative, doing at a conference in a communist country? At the closing ceremony, she bluntly explained that the World Bank fears the AIDS pandemic will trigger "regional economic collapse." Their view is that economic disaster is a fate worse than socialized medicine. She suggested that the developing world adopt Cuba's medical model as the strategy for fighting the pandemic. Ms. Zewdie from the World Bank wasn't the only world specialist who recognized Cuba's superior way of dealing with AIDS. At the opening plenary, UNAIDS executive director Peter Piot praised Cuba as "one of the first countries to take AIDS seriously as a problem and provide a comprehensive response combining both prevention and care." What is it about Cuba's medical system that both adversaries and friends hold in such high regard? When AIDS exploded 23 years ago, the scientific world was shocked. Thinking among many western health care researchers was that infectious disease was in the main conquered. They thought that the biggest medical problems were going to be diseases of life style and/or industrialization. Therefore they were not prepared psychologically to deal with HIV when early reports were published. Some knew better. The reaction of the Cuban's was critical at that point. In 1983, two years before the first case of HIV appeared in Cuba, they had already set up the National Commission on AIDS to educate their population. Dr. Byron Barksdale, director of the American Cuban AIDS Project, believes that Cuba's early reaction is the basis for its very low contemporary infection rate. Social advances had gone hand in hand with medical advances Cuba made through the years. By the time AIDS broke out, complete popular access to health care was a reality. That Cuba has set up special faculties to teach about HIV/AIDS is no surprise. But Cuba has also set up medical schools for other Latin Americans, U.S. citizens, and other nationals. Presently, even with Washington's criminal embargo in place, hundreds of Americans, on full scholarships study in Cuba. Almost 14,000 students from 113 countries also study on scholarship. As of 2004, 17,654 students had graduated, 70% were from African countries. An important focus of their education is that their skills must be used to help people who have the greatest need, wherever they practice after graduation. Now, after 20 years of dealing with HIV and making necessary corrections, this is what the Cuban system looks like. Medical care is not a business. Hospitals aren't run like hotels that need to have 100% room occupancy. Prevention is understood to be the best, cost-effective approach to any illness. The prevention program should be divided into two broad areas, education and screening/testing. There are radio and TV messages, posters all over the country, and prevention centers in Havana and other major cities. The centers include professional medical staff, and volunteers and activists living with HIV/AIDS who, because of their education and life experience, are excellent educators. Supported by the UN Population Fund, the Education Ministry provides national sexual education for junior high schools. The national prevention program is not limited to "abstinence only." It gives a broad range of messages designed to raise awareness of all transmission routes that HIV takes. These prevention messages and programs address condom use and other safe sex practices for those sexually active, and the necessity for clean needle and "works" use by intravenous drug users. Personal responsibility of HIV+ people not to infect anyone else is stressed. Education also includes providing alternatives to breast-feeding for HIV+ mothers with newborn children, workplace policies to prevent accidental occupational HIV transmission, and targeting groups of people with high infection risk. In 1993 many Cubans living with HIV/AIDS joined the National Commission on AIDS to help make the best decisions regarding prevention and treatment. El Grupo de Prevencion del SIDA (GPSIDA, AIDS prevention groups located in Havana and in all the provincial capitals), together with the Sanatorio de Santiago de Las Vegas and the Ministry of Health, held a national conference to identify the most pressing needs of the prevention workers and to improve delivery of services. Screening and testing begins with blood and blood products. Since 1983, all blood products from countries reporting cases of HIV/AIDS have been banned. Beginning in 1986, blood donations have been screened for HIV. Over eight million screens have been done, with 374 HIV+ samples being found. De facto HIV transmission through blood products has been eliminated. In 1987, surveillance of pregnant women was established. Mother-to-child transmission (MTCT) was reduced to less than 2% of the 170 HIV+ women who gave birth, and it improves each year. The key to reducing MTCT was getting every pregnant woman into prenatal care as soon as she found out she was pregnant. MTCT reduction goes hand in hand with Cuba's 2003 infant mortality rate of 6.3/1000 live births. (Total U.S. infant mortality rate in 2001 was 6.8/1000. The U.S. Black rate was 14/1000.) We must always remember that unprotected sex, for pro-creation or recreation, is "unsafe" when looked at from the perspective of HIV transmission. Intelligent people agree that education changes lives and opens doors welded shut due to ignorance. Because of Cuba's HIV education, the population understands both the individual threat and the social importance of controlling HIV. Most testing is voluntary. The exceptions are blood donors and prison inmates. Because of the effectiveness of the education, the voluntary groups include even: * People with any sexually transmitted disease * People with HIV-related opportunistic infections * People suffering from tuberculosis. (Tuberculosis is the world's number-one opportunistic infection. Such infections result from immune system dysfunction.) * All pregnant women * Sexual partners of HIV-infected people (part of the partner notification program) * People whose family doctor recommends testing * Anyone who is worried about being exposed. Confidential and/or anonymous testing is also available all over the country. Despite education and prevention work, some new infections occur. Explanation for this could be found in the folk saying "When the penis stands up, brains go out the window." Safe sex goes out the window as well. In the '80s, a Cuban diagnosed with HIV was required to take a several-month course at a sanatorium about the impact of HIV and what to expect from the illness physically, emotionally and socially. The first sanatorium, Sanatorio Santiago de Las Vegas, was established in 1986. Presently there are sanatoria in all Cuban provinces except Las Tunas. Today, going to a sanatorium is decided on a case-by-case basis. The purpose of going to a sanatorium is educational, not punitive. It is very important to realize the impact that "catching" HIV had on a person before 2001, when the first effective treatment, the "cocktail," came into widespread use in Cuba. Before then, HIV was considered in many cases to be a death penalty because there wasn't enough medication for all infected people who needed it. They had to rely on humanitarian aid to get what little medication they had. The cocktail came into widespread use in the industrialized world in 1996. During the first year, the death rate declined 40% in the United States and 80% in Europe. Yet, even today, the criminal U.S. embargo prevents Cuba from buying any kind of medications anywhere on the world market. Pharmaceutical companies are given a choice between selling in Cuba's market of 11 million people or in the US market of 250 million. At the sanatoria, medical doctors, nurses, psychologists, nutritionists and people with HIV educate the newly diagnosed person. Depression and nutrition education are two areas of the illness that most lay people don't know about, but it is critical to treat them if a person is going to respond properly to medication. Another crucial therapeutic point is that patients cannot be fired from their jobs. They continue to receive a salary while under treatment. A newly infected person feels enormous stress upon getting an HIV diagnosis. It would be exacerbated if they feared for their job and income, especially if they have a family to care for. Their sexual partners are contacted and educated about the importance of being tested. At the sanatoria, meals are provided and food is plentiful. Food rationing, because of the U.S. embargo, is suspended for the sanitaria. Nutrition education, proper eating habits partially dictated by the medication a patient is taking, and their role in defeating HIV, are presented at every meal. After the patient graduates from the sanitarium course, he/she is free to leave and resume regular life or stay on at the sanitarium. Many chose to stay on to be trained to work within the HIV/AIDS community. I have visited the Santiago de Las Vegas sanitarium. My first impression was that I was in a tropical resort facility. Patients live in attractive, multi-room cottages arranged along tree-lined lanes. There are medical facilities, workshops, vegetable gardens, and athletic fields. The horror stories I had heard in New York about the sanatoria were clearly lies. My favorite recollection is an encounter there with a worker-resident that I had originally met in Brooklyn. We asked each other the same question. "What are you doing here? " She was there working, living and getting medical care. After coming to New York, becoming HIV+, and having to deal with our system as a poor person, she returned to her homeland where she was better off. Why is it that we never hear about the Cubans who live better after they return home? Of course Cuba has made mistakes. In the early '80s AIDS was known as Gay Related Immune Deficiency, GRID. Blaming gays supported the institutionalized homophobia that existed in Cuba before the 1959 revolution. It required education to eliminate that prejudice. Mandatory quarantine was the rule when AIDS first appeared. It ended in 1993. Quarantine is a universally used public health tool. When the transmission route of an illness is unknown, it is an effective way to protect the public from infection. The World Health Organization used quarantine to help stamp out the Ebola Fever outbreak in Zaire in 1976. More recently it was used against SARS and is currently used against TB in New York. After 1993, ambulatory care became widely available through the Sistema de Atencion Ambulatoria. People with HIV can get care through their family doctor or at a specialized local clinic in Havana, such as Pedro Kouri Institute for Tropical Medicine (IPK) or at provincial sanatoria. At IPK, and other clinics, decisions about medications are based strictly on medical guidelines and discussions between patients and doctors. Questions of money or medical insurance have no place in the discussion. Since 2001, Cuba has produced its own generic HIV medication, anti-retrovirals or ARV. Thus many ARV cocktails, made up of three or more medications, are available. But the AIDS virus's ability to mutate and defeat the efficacy of the cocktail remains a problem. When it mutates and is no longer under control, patients need to change one or more components of their cocktail. This happens periodically. The U.S. embargo prevents Cuba from importing the latest ARVs from the U.S., or anywhere else. There is a serious lag time between the invention of a new ARV and Cuba's production of a generic version so a patient can use it. Consequently, there is still a need for a world movement to collect and donate medical supplies to Cuba. Since the 1959 revolution, international solidarity work has been Cuba's passion. The amount of help Cuba has given the world's oppressed is truly amazing. It is therefore ironic that soldiers, doctors and others helping the South Africans cast off the yoke of apartheid brought HIV back home in 1985. But no other society created a system reproducible by other poor or developing countries hit by the AIDS pandemic. Cuba has sent more than 17,000 health care workers to 65 countries to provide care and education that simply wouldn't be available otherwise. It sends medical teams to Venezuela to help set up health clinics. During the recent U.S.-orchestrated Haitian coup, Cuban medical teams, at great risk, continued to offer care to anyone needing it. They have also helped Brazil respond to its AIDS crises with generic ARV medication formulas. Recently Cuba offered generic HIV/AIDS medications, at very low prices, to all Caribbean nations. Currently, Cuba has the ability to slow down the impact of AIDS throughout the developing world. This isn't to imply that they have a cure. What they do have is a medical system that can adapt to different cultures. What they need is material aid from the developed world so that the program can be put into place in other societies. This is not likely to happen any time soon. The United States, and the corporate world stand in the way. In contrast to Cuba, how did the U.S. react to the threat of AIDS? During the early days of the epidemic Ronald Reagan was president. He managed not to utter the word AIDS for six of his eight years in office. The U.S. media helped him maintain that silence. They continued to use the incorrect term GRID, further demonizing gays, even after the Center for Disease Control coined the term AIDS in 1982. In the U.S. blood banks used their existing supplies and refused to screen their blood until 1985. Thousands of hemophiliacs became infected and many died through contaminated blood clotting agents between 1982 and 1987. Congress passed the Ricky Ray Relief Fund of 1998 authorizing payments to the victims. Our lives have dollar values decided by other people. The U.S. has invented an impressive variety of ARVs and other medications since 1981. Much of it paid for with public money. But long before the regime of Dubya and after Reagan's "vows of silence," access to these medications by all our citizens wasn't the rule. Disparity in access to health care still plagues us. People are still dying from AIDS because they haven't been tested or they can't afford life saving medications. Many doctors consider race, gender, age and income before they prescribe ARVs. The federally funded Aids Drug Assistance Program, ADAP, has access restrictions and waiting lists in 16 states. Buying cheaper medications from Canadian outlets is prohibited. What we see here is multiple embargoes that protect profits at the expense of human life. The Clinton Administration maintained the embargo against Cuba and blocked the sale of generic ARVs to South Africa. Thailand was prohibited from producing ARVs for its own use. Clinton's administration also defeated a needle exchange bill. In 2003 New Jersey saw a 46% rise in new HIV infections as a result of dirty needles. Currently there are 36 states where it is legal to fire a person for being lesbian, gay, bisexual or transgendered. If you lose your job you usually lose your medical insurance unless you can pay for it yourself. I think that the greatest fear the U.S. government has about Cuba's health care system is that Americans might start asking key questions. Why does Cuba, with very little money, have such an advanced medical program? Why does the United States, the richest country in the world, operate a medical "system" that would be the envy of societies that existed in the Middle Ages? The problem is not with our health care workers, who are on par with the best in the world, but the profit-dominated system we have to work in. The United States cannot export or sell its dollar-based medical industry because its "sex education and reproductive health services abroad are contributing to childbirth and abortion related deaths as well as the global spread of HIV among women," according to the Countdown 2015 conference recently held in London. According to the UN Development Fund for Women cited in HIV+, 10/04, "The proportion of new HIV cases among women in the US is increasing at the fastest rate in the world." Overall the United States has had at least 40,000 new HIV infections each year since 1992. We don't know the exact number because only 48% of adults have been tested. We don't have universal testing. 2003 gave us 5 million new HIV infections and 3 million deaths worldwide. It was the worst year of the pandemic. Instead of health care, the United States sends thousands of soldiers to more than 750 military installations in 130 different countries to impose the dysfunctional U.S. system on the local population at the point of a bayonet. Cuba has thrown out the profit motive in medical care and elevated the value of human life to where it belongs--to the most important position. It has shown the world that it isn't the failure of science that keeps us from making giant strides against AIDS, but social and political ideas. It is our responsibility to do what we can to accomplish its goal"defeat AIDS. Edwin Krales, Certified Dietician/Nutritionist, is an HIV/AIDS Nutritionist and Health Educator, working and living in New York City. This article is reprinted from counterpunch with permission from the author.