A “toxic mismatch” in Havana

A student’s research on Cuban HIV policy shows the potential for higher rates of infection.

For years Cuba had the distinction of being the only country in the world to quarantine people who tested positive for HIV. One of a handful of remaining communist nations, Cuba took pride in comparing the success of its approach with the failures of capitalist nations to contain the disease. But all that is changing, reports Helena Hansen, an M.D./Ph.D. candidate at Yale who spent six weeks in Cuba in 1997, interviewing physicians, public health professionals and people with or at risk for HIV infection.

She found a growing recognition among health care professionals that a new strategy is needed as tourism becomes the leading industry and Cubans flock to the cities to become entrepreneurs in a new, dollar-based economy. “There are many social changes taking place because the economy has changed so much,” Hansen said in January during a talk that was part of the Humanities in Medicine series.

Change in health strategy faces formidable obstacles in Cuba, where universal health care has been a cornerstone of social policy since the 1959 revolution that brought Fidel Castro to power, Hansen said. Cuba eradicated polio, diphtheria and other diseases endemic to other Latin American nations. The island has twice the number of doctors per capita as the United States and significantly lower infant mortality rates than its Caribbean neighbors. Even after Cuba lost its principal financial patron with the breakup of the Soviet Union, the government continued to invest in health care and promote a small biomedical industry. Although fuel, food, housing and consumer goods remain scarce, the government points to health care as a benefit of the revolution.

Cuba’s centralized, authoritarian approach to public health allowed it to report one of the lowest incidences of HIV in the hemisphere. In 1997, Cuba had 1,609 cases of HIV and 600 cases of AIDS in a population of 11 million—compared to more than 21,000 cases of AIDS in Puerto Rico, which has a third the population. Cuba banned foreign blood products and monitored its population for diseases that indicated the presence of HIV. Surveillance was so precise that health officials could say with certainty that AIDS came to Cuba in 1985, carried by a bisexual theater worker who had traveled to New York and several soldiers returning from Africa.

“The decision to quarantine HIV-infected citizens reflected a classic approach to public health that Cuba had exercised with success,” Hansen said. But, by 1996, despite the containment strategy, HIV infection was increasing. Popular tourist spots in Havana and elsewhere in Cuba, Hansen said, are witnessing a phenomenon unseen since the days of dictator Fulgencio Batista—the emergence of street hustlers called jineteros. Today’s sex workers come from diverse backgrounds and can be college students, doctors or lawyers who occasionally turn to prostitution to obtain U.S. dollars and access to scarce consumer goods, Hansen said.

In response to pressure from international human rights organizations, Cuban health officials have relaxed their quarantine. People with HIV are advised, rather than required, to spend six months in a sanatorium to learn, among other things, safe sex and behavior modification, but the country has not yet embarked on a comprehensive AIDS education program. Monitoring of HIV-positive people and the tracing of their sexual contacts remain the mainstays of current policy. Scarcity of condoms and a culture of aversion to condoms limit their use. The simple possession of a condom, Hansen said, can label a woman as a prostitute plying the tourist trade. And the illegality of prostitution and strong stigma of homosexuality drive underground two groups at risk for infection. Although the government supports one official AIDS prevention group run by HIV-positive Cubans, it is illegal for other groups to organize without official sanction. Nevertheless, Hansen said, gay men report that recent government promotion of tourism has created a more liberal atmosphere that allows gay clubs and hotels to operate.

“A toxic mismatch may be occurring in Cuba,” she said, referring to the high social and geographical mobility of Cubans in the face of inadequate HIV prevention programs. She notes that when it comes to AIDS, revolutionary ideas and a centralized medical bureaucracy may be at odds with the realities of a changing society.