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    An Island of Health without Wealth 1

    An Island of Health without Wealth

    Research Analysis: Cubas Health and HealthcareThrough a lens focused on HIV/AIDS Treatment and Research

    Team 4:

    Wendy Carrillo, Mahnaz Jeddi, Heather Kindred,

    John Retherford, Adrian Wilson, & Sarah Queener-Plourde,

    Global Health

    Professors Bantz and Li

    December 10, 2008

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    Medicine and healthcare cannot be isolated from the cultural and political realities

    they are encompassed by. They are intricately and critically connected to each other

    within any particular society (Payer, 1988). In the United States healthcare is treated as a

    commodity. Like any commodity it is distributed by market forces according to an

    individuals ability to pay (Payer, 1988). In the US we live in an era when healthcare is

    dominated by the treatment of chronic long term illnesses, when long range mass transit

    spreads new viral strains and antibiotic resistant super-bacteria around the world in days,

    and when constantly diminishing access to the healthcare system across social spectra is

    unsustainably driving up costs for the system as a whole.

    To rein in costs and maintain public health society must provide universal access

    to local health care services including preventive services, health counseling, and health

    education (Center of Disease Control and Prevention). This is only possible if the

    commodity healthcare paradigm shifts to considering healthcare a universal human right

    (Hong, p. 28). Cuba is a nation that strives to live up to this standard. Cuba delivers

    healthcare in a cultural and political context quite different from that of the United States.

    Cuba guarantees cost-free healthcare locally to every citizen, and despite major economic

    and political obstacles it achieves remarkable health outcomes efficiently and equitably.

    Cuba has pioneered a system of medical diplomacy in which it provides medical

    personnel and medical training to developing countries as an instrument of trade policy.

    Through its Comprehensive Health ProgramCuba educates and treats its rural and urban

    populations, while implementing medical solutions globally (Council on Hemisperic

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    Affairs). This strategy develops and strengthens valuable diplomatic and trade

    relationships while strengthening Cuba domestically by providing its citizens with much

    needed healthcare resources, natural resources, and commodities. This is one of the

    ingenious policies Cuba has adopted to deal with the severely restrictive US trade and

    travel embargos.

    To the Republic of Cuba, being isolated and left to its own local resourcefulness

    is not a new concept. In fact, we could rightfully say that Cubans are masters of solidarity

    (Thompson & Gaviria, 2004). Survival knowledge transfers into all activities of daily

    life from one generation to the next. Without question, the embargos have made life

    harsh for Cubans in many ways. Yet sometimes things with the potential to destroy

    culture and remove life became a source of unifying strength, solidarity, and mobilizing

    prowess. This sense of solidarity pervades nearly all aspects of Cuban life and culture.

    Every country has its own culture and way of presenting itself. Entering another

    culture can sometimes be a shock, but the best way to deal with this is to show respect for

    how others choose to live life without analyzing it like a tourist or a film critic (Palomar

    College). This respect can only be delivered by preventing one's own way of thinking

    about perceived differences to interfere with the experience of immersion and learning

    someone else's way of doing things. Listening and observing with a quiet mind is very

    difficult task (Chawla & Renesch, p. 266-7). This can be especially true for Americans,

    many of whom believe their political and cultural ideals are the only or at least the best

    definition of liberty, democracy, and justice (Kohut & Stokes, p.127).

    This is a type of subconscious rejection and is one of the ways in which one

    culture dominates and displaces another in order to establish hegemony. On the other

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    hand, a consciousness of equality demands acceptance and respect. Disrespect remains a

    major reason for conflicts, persecution, and genocide (International Peace Research

    Association). As Americans we must face our own biases, our misinformed and

    disinformed thoughts about the culture and customs of the Cuban people, and about the

    Republic of Cubas core social policies. If we do so we could learn important lessons

    about how this small and isolated yet influential country has become a world leader in the

    autonomous management of medical research, education, and healthcare delivery,

    domestically and internationally (Gorry, 2008).

    One central objective of Cuba's Constitution is to entitle all its citizens with a

    right to free, quality medical care (Center for Latin American Studies). Cubas

    government has rejected the use of medicine as a means of generating profit. In this

    environment providers are incented more by a desire to make people healthy than by a

    desire to maximize profits. Cuban doctors spend their days at their clinic but still make

    house calls in the evenings (Salud International) largely because doing so is better for

    their patients. Even though medical services are provided to all Cubas citizens, medical

    supplies such as gloves, syringes, aspirin, general medicines, and medical equipment are

    not always available. In fact, patients often have to supply their own linens and personal

    hygiene items when at the hospital (Sixto, 2002). Despite being considered an

    underdeveloped, third world country, Cuba is nationally respected and admired for its

    leadership, advancements, and contributions to local and global medical research and

    healthcare delivery (Gorry, 2008).

    Education, especially reducing illiteracy, is one of the most effective and efficient

    ways to reduce illness and disease in a population (not to mention its social and cultural

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    benefits). Quality education is another priority of the Cuban government. Before 1965,

    Cubas literacy rate was around 60%, but those figures have since risen to 96%. Cuba

    now rates second among all Latin American countries. Elementary education is

    mandatory between ages of 6 to 16, and free college or specialized training for a local job

    market is offered freely to everyone. Cubas curriculum for primary education includes

    learning about herbal medicine, renewable energy and climate change, information on

    AIDS/HIV prevention, as well as several hours a week working in an agricultural

    community.

    Cuba's youth are well prepared by their educational system for the local and

    international work force.(Inter-American Commission on Human Rights, p.6). It also

    enhances their quality of life providing a richer sense of cultural grounding and

    connectedness. In his book Dreams from my Father Barak Obama emphasized how

    important this type of educational system is to learning by quoting Dr. Asante King, a

    Chicago school principal, describing what he believes a real education for black children

    would involve:

    This model would be applicable to all races and it is apparent that Cuba's

    educational system follows this model despite its small size and dense population. Cuba

    is roughly the size of Louisiana (Smith, 1921) with over 11 million inhabitants.

    "It would start by giving a child an understanding ofhimself, his world, his culture, his communityThat's what

    makes a child hungry to learn-the promise of being a part ofsomething, of mastering his environmentFrom day one he'slearning about someone else's historysomeone else's

    culturethis culture he's supposed to learn is the same culture

    that's systematically rejected him, denied his humanity,"(Obama, p. 258).

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    Louisiana, on the other hand, has a little over 4 million inhabitants (Robins & Trujillo,

    2006). Cuba has, none-the-less, provided its citizens with unique comprehensive services

    that rival most developed countries around the world, not only with health care but with

    the over all wellbeing of its citizens, in sickness or in health (COHA).

    The Cuban philosophy of health is based on the belief that disease prevention is a

    more effective approach than treating a disease after it manifests. In 1984 Cuba

    developed its Doctor-Nurse Family Team Program, which is a very effective poly-clinic

    networking system, whereby each neighborhood has its own primary-health-team

    specializing in disease prevention and education(Gorry, p.10-11). Cuba's intervention

    programs effectively target specific high risk groups as well as the general population.

    Cuba's holistic community-based approach puts the health and "illness aversion"

    of all its citizens at the center of government spending. Despite Cuba's size, it has 21

    medical schools, 20 hospitals in Havana, and 40 rural polyclinics (Inter-American

    Commission on Human Rights). The U.S. for-profit healthcare system spends $6,000 per

    capita per year, while Cuba's Universal healthcare costs a mere $320 per person (Cooper,

    Kennelly & Garcia, 2006).

    Cuba sets a global example caring for its own citizens. It is also developing

    superior medical initiatives in cancer and AIDS research, which in turn have created trade

    partnerships and alliances among the world's neediest countries. Cuba currently hosts

    3,400 medical students from 23 countries, many being subsidized by the Cuban

    government. Cuba has developed a world leading, highly sophisticated, Biotech Industry

    that supplies inexpensive generic drugs to a global market that currently includes 50

    counties (Health Care Systems in Comparison, 2007). It is truly remarkable that Cuba

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    has overcome its forced isolation to become a global leader in the fight against the

    HIV/AIDS epidemic. For the impoverished developing world, which is often unable to

    afford expensive exported treatments from the United States, Cubas leadership had

    created a real sense of hope.

    The HIV/AIDS virus in Cuba was first detected in 1986 among returning soldiers

    from Angola and Mozambique (Boadle, 2005). The chosen technique to deal with this

    crisis was quarantine and surveillance in specialized facilities called Sanatoria. This

    approach has proved to be one of the most effective in the world at preventing the spread

    of the disease. As a preventive measure, Cuba performs mandatory but confidential

    screening of high risks groups including those returning from abroad, its homosexual

    population, and Mothers to be(Gorry, p.4).

    Along with these measures, the Sanatorias first built to house and isolate returning

    infected soldiers have since become housing and long term care facilities for those

    diagnosed with HIV/AIDS. Cuba uses its limited resources to provide everything they

    can to people with this life threatening condition. Education about risky behavior and

    prevention is heavily emphasized. Condom use increased from 47% to 69% between

    2001 and 2006. In 2004, over 90 million condoms were sold and made easily attainable

    within the communities (Gorry, p.13).

    Socially isolating the virus does not include socially isolating the person from

    what makes him/her a member of that socio-economic community. Their civil liberties

    remain in tact, along with their personal effects (Feinberg, 2006). In fact, they are so

    protected from social isolation that the Cuban government enforces anti-bias philosophies

    for potentially marginalized communities (Garcia & Daniel, 2001). Additionally, after a

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    six months stabilization period, patients have the choice to live at the Sanatoria or in their

    home. In the U.S. there is no such choice unless you can pay for specialized long-term

    care. In Cuba there is no dehumanizing stigma. In Cuba one can keep their job and their

    wages, and can continue to be loved by their family and community. Cubasjoint

    government-citizen responsible response to the needs of the larger community has a

    dynamic message to send to the masses (WHO, 2004). The policy aids a person in living

    to their fullest potential despite a debilitating illness. They enabling patients to keep their

    human dignity and are certainly a model for the world to learn from.

    The U.S. and Cuba deal with the same social issues in drastically contrasting

    ways. According to Avert International Aids Charity Organization the United States HIV

    outbreak was practically ignored until late in 1981, time in which the virus spread to

    other populations of gay men and injection-drug-users (2008). By July 1982, 452 cases

    had been reported to the CDC from 23 states. By the end of 1982 it had become clear that

    the disease was appearing in European countries as well. Another article reported

    disturbing estimated figures:

    While the numbers are difficult to compare directly Cuba has a new infection rate

    of only .015% over a 15 year period, while the U.S. has a new infection rate of .017% in

    the year 1997 alone. Even after accounting for the difference in population size Coburn

    and Burrs data indicate that in the history of the epidemic 35 people in the US die of

    "In 1997, 45,000 people out of the 260-million Americanpopulation will become infected with the AIDS virus, and so far over362,000 Americans have died; Cuba, with an 11-million population,has since the start of the epidemic seen 1,681 infected."So far, [at thewriting of this article] 442 have died."

    Coburn & Burr, 1997

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    AIDS for every 1 AIDS related death in Cuba. The number of reported AIDS cases in

    Cuba is the lowest in the Western Hemisphere (Uriarte, 2002).

    This emphasizes that Cuba has the experience and expertise to respond quickly

    and efficiently to disastrous situations when they happen. In the beginning of the

    outbreak, Cuba understood that HIV/AIDS was an infectious disease that could infect

    anyone in the entire population, regardless of a person's sexual behavior. In 1987 Cuba

    launched the National Program for Prevention and Control in Havana. HIV test kits

    became available and 33 research laboratories were established. A free Generic Anti-

    retroviral drug was developed in 2001. One other very crucial step Cuba took to prevent

    an epidemic to dispose of some 20,000 imported and possibly infected blood products

    and make blood screening standard practice as early as 1986 (Gorry, p.6-8).

    The U.S. embargo has left Cuba extremely restricted from imports of simple but

    essential medical supplies that they themselves cannot manufacture (Farag, 2000). It

    cripples Cubas ability to deliver treatments and conduct research. With Cubas wealth

    of experienced personnel this stifling effect does significant damage to world efforts to

    combat HIV/AIDS. What Cuba has demonstrated foremost is that health and wellness

    can be a national priority. Public expendetures can efficiently and effectively provide free

    universal health care and education to the public. Access to health and medicine need not

    be dependent on ones ability to pay. What Cuba has also demonstrated is that rapid

    response and isolation of a life threatening epidemic disease (and government

    coordination of interventions, education, and medical research) is essential to controlling

    potential outbreaks.

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    To the United States Cuba may well be the most controversial, misunderstood,

    and neglected foreign neighbor. Yet many facts about healthcare and health in Cuba are

    laudable. Equality is a social policy that promotes, guarantees, and distributes adequate

    basic human rights necessary to sustain life. Disparity and social policies that create

    inequality, on the other hand, increases poverty, create discrimination and disparity, and

    damage the health of entire populations (Betzruchka, 2004). Inequality creates an

    environment of disease, illness, and high mortality. Solidarity is what a people bound to

    one another through their history and culture can have while surviving all odds together

    as a Nation.

    Cuba leads the world in promoting responsible choices for the entire world

    population. Disease management knows no borders or boundaries. Recognizing this

    fundamental truth Cuba not only develops solutions to its own crisis situations, it

    responsibly shares its expertise and its resources (as limited as they are) with other

    struggling countries. Cuba sets a humanitarian example for the world to follow despite

    low economic output. In 1989, when the Soviet system collapsed, Cuba was 85%

    dependent upon them for imports and exports. It quickly had to develop creative means

    of surviving. Yet when Cuba's need was at its highest, the U.S., its closest neighbor,

    made the embargo restrictions even more severe, in the minds of some bordering on in-

    humane and genocidal. Cuba continues, none the less, to send its star, out to an ailing

    world. If the world looks carefully it might find valuable lessons contained in this island

    of health without wealth.

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