At the height of the Cold War in 1959, Fidel Castro seized control of Cuba after overthrowing the President Fulgencio Batista. As the leader of the Cuban Revolution and a successful coup against Batista, Castro was determined that Cuba became a communist state. Castro had the support of the former Soviet Union as the Soviet Union was deep in conflict with the United States of America, and Cuba was of great geographical interest to the Soviet Union (Feinsilver 1993:10). By supporting his revolution, the Soviet Union believed Castro could “subvert Latin America and the Caribbean with potent Marxist-Leninist ideas” (Harries 1996:127). Fidel Castro established a single party government in Cuba and was appointed Prime Minister with dictatorial controls. Castro implemented socialist policies such as wealth and land redistribution, as well as an emphasis on education and healthcare. He often publicly spoke his support of health workers, once calling them, “moral collective, profoundly ethical, that constitutes the very essence of the Revolution” (Andaya 2009:358). To spread Castro’s vision of single party government, Cuba began sending groups of soldiers, social workers, and health professionals to developing parts of the world (Farmer 2003). These groups, called internationalistas, traveled to third-world countries, like Africa, in need of aid. While this policy allowed Cuba a larger foreign policy presence, this same policy was the culprit behind the spread of HIV to Cuba in 1985. At the time, several Cuban soldiers were working to keep the peace in Africa (Parameswaran 2004).
In 1956, the oldest genetically characterized HIV was discovered through blood tests of a man living in present day Kinshasa, Democratic Republic of Congo (Essex 2002). There are two types of the virus, HIV-1 and HIV-2, with HIV-1 being more pathogenic and more prevalent worldwide. Both types are believed to have emerged in Africa, from monkey to human cross-species transmission of the simian immunodeficiency virus (SIV) in the early 1900s (Hutchinson 2001). From this first transmission, the virus quickly spread to neighboring countries. Due to the highly pathogenic nature of the virus, increased globalization and transcontinental movement of people, the disease quickly spread worldwide. Around the time HIV became endemic in Central Africa, the Cuban Ministry of Public Health began testing all residents returning from Africa for HIV and various other diseases; later, HIV screening became mandatory for the entire population (Bayer 1989). The Ministry established the National AIDS Commission in 1983 with the goal of complete prevention and put Dr. Jorge Perez Avila in charge (Fink 2003). This rapid response even beat the World Health Organization, which did not create their Special Programme on AIDS until 1986 (Whiteford 2000). There were four main goals established by the National AIDS Commission, all of which were focused on prevention:
“[1] develop a national prevention programme for the general population and for specific risk groups; [2] develop a national network of sanatoriums to admit all persons detected as HIV positive’ conduct epidemiological surveillance and control; [3] lead scientific research and biotechnology production in this area; and [4] make sustainable efforts for the prevention of mother-to-child transmission of HIV, the prevention of HIV-related opportunistic infections; and the prevention of AIDS itself” (WHO 2004)
The program immediately began halting all travel of blood products into the country. Hospitals instigated surveillance system meant to detect possible diseases relating to HIV (Granich 1995). Any persons having come into contact, especially sexually, with an HIV infected individual were tracked down through the Partner Notification Programme (World Health Organization 2004). Cuba’s swift action saved many lives, especially with regard to blood import and donation, “these actions may have prevented hundreds or thousands of needless infections, the likes of which other countries that didn’t implement such ideas suffered” (Fink 2003).
As global health concerns continued to grow, Castro charged the Minister of Public Health with “the responsibility of ensuring that the epidemic ‘does not constitute a health problem for Cuba’” (Anderson 2009). The original policies set up by the National AIDS Commission worked for a few years, but in 1985 HIV spread to Cuba. Internationalistas continued returning from Africa HIV positive. Around the same time, HIV began appearing in the gay and bisexual community, although these individual’s contracted the virus mainly in Europe and North America (Farmer 2003). While the blood screening, Partner Notification, and surveillance system were important aspects of the program, the most drastic, controversial and arguably the most successful aspect of the program was creation of sanitariums.
The first sanitarium was named Santiago de Las Vegas and was located in Havana. The sanitarium was constructed by the military to quarantine HIV positive individuals to reduce transmission of the disease. The military initially created the sanitariums for returning infected internationalistas. However, soon after it was built, the number of infected civilians began to outnumber the internationalistas so the military quickly handed control to the Ministry of Public Health. The Ministry of Public Health in turn gave control to the Director of the National AIDS Program, Dr. Jorge Perez Avila, who eventually created fourteen more sanitariums spanning the country (Fink 2003).
The intake procedure of the sanatoriums involved first identifying persons infected with HIV and placing them in the closest sanitarium. In the sanitarium, residents were appraised to see whether their condition was serious enough to further transmit the disease to their communities. If the residents were deemed satisfactory, they were allowed a short time away from the sanitarium without the need of a supervisor to accompany them; unsatisfactory residents were accompanied by a supervisor if they wished to leave the sanitarium for any period of time (Granich 1995). These appraisals occurred often, and the satisfactory and unsatisfactory labels changed frequently. Santiago de Las Vegas was originally built like military barracks, but Dr. Avila quickly tore down the fences and outfitted the sanitarium with houses, apartments, and recreational facilities. Residents of Santiago de Las Vegas were able to keep their existing salaries and continued to work. Patients also received food, medicine, and housing at no added expense. A full staff of social workers, physicians, nurses and psychologists were available to the patients and the level of care exceeded the Cuban national standard. Residents of the sanatoriums were given diets high in vitamins and nutrients; high amounts of protein was also a treatment component. Over time, the Cuban governmental policy regarding sanitariums and the amount of contact allowed among HIV infected residents evolved through three phases. Starting in 1986 and lasting for three months, phase I involved removing HIV infected persons from their homes and relocating them to sanitariums, where they were forced to remain; visitors were permitted. Phase II authorized sanitarium residents to leave the sanitarium “for 18 hours four times every three months” under supervision. Under phase III, which began around 1989, certain residents were given permission to leave the sanitarium without a supervisor.
In 1993, an outpatient system was established that allowed HIV patients the freedom to live outside the sanitarium but return for necessary treatment. There were several criteria a patient had to meet before being awarded outpatient status. HIV patients had to agree to disclose the names of their sexual relations, in order for the Cuban government to track their partners. A year later in 1994, the long-standing quarantine ended; HIV patients were no longer required to spend the rest of their lives at the sanitariums. The Cuban Ministry of Health posed a question to the residents of the sanatorium as to whether they wanted to return home, or if they wanted to remain living in the sanitariums (Granich 1995). Almost half of the residents chose to remain in the sanatoriums. The recent collapse of the Soviet Union had demolished the economy of Cuba, and income was down by half. This collapse severely affected the lower class, making it harder to find jobs and take care of their families. Many decided to stay because the conditions at the sanitarium, with free food, housing and air-conditioning, were better than what they would face if they returned home. In fact, some people were so desperate that they deliberately injected themselves with HIV to receive the benefits of the sanitarium (Smallman 2007). Many also stayed for the sense of community; the forced quarantine forged a strong sense of community and belonging that was not available outside the sanitorium.
Today, only three of the fourteen sanitariums remain. Since the lifting of the mandatory quarantine, more patients have willingly come forward to be tested for HIV, reducing the chance of accidental transmission. HIV patients today spend at least three months in the sanatoriums in order to learn how to live with HIV. Patients also learn how to take the required HIV medication as well as how to reduce the risk of spreading the disease to others. The length of time a person stays in sanatorium depends on their support network, their commitment, and whether or not they are responsible enough to be treated as an outpatient. Some HIV patients are attracted by the sense of community and the benefits of living in a sanatorium, so they decide to remain permanently. Dr. Avila “estimates that 52% of patients are currently in the ambulatory care system and 48% are in the sanatorium system” (Fink 2003).
There were many factors involved that made the sanitorium even a possibility in the world today. One of the most important is Cuba’s universal health care system. Highly prioritized by the state, healthcare in Cuba became “a high-quality primary care network and an unequaled public health system…controlling infectious diseases” (Esposito 2016:29). Influenced by the Alma-Ata Declaration, Cuba’s National Health System was founded upon the ideology that healthcare should not be for profit, but is an essential human right that the state is responsible for funding. Public participation is an essential part of the development of the healthcare system. A model of wellness was constructed in order that the healthcare system be aligned with the needs of the Cuban people; the determining factors of this model were personal characteristics and physical and social environments. Six hierarchical levels comprise the delivery system of the NHS: 1) Neighborhood primary care by family physicians; 2) Sector primary care by policlinicos or polyclinics; 3) Area primary care by polyclinics and health centers; 4) Municipality secondary care by specialized hospital centers; 5) Province tertiary care by specialized hospital centers; and 6) National quaternary care by highly specialized hospital centers and health institutions. The six hierarchical levels readily integrate into one another, and are associated with the Cuban departments of politics and administration. The Ministry of Public Health mandates the training of medical professionals and health workers, by outlining “the knowledge base, competencies, and scope of responsibility for each of the university-level health sciences professions” (Keck 2012). Another factor is the cultural principles of Cuban citizens; Cuba is organized along greatly different principles from those found in many other countries. The interests of the state and community are placed before individual concerns. “Residents of Havana with whom we spoke frequently expressed the view that collective well-being takes precedence over individual rights” (Granich 1995:8).
While the sanitariums were highly successful, Cuba achieved the lowest rate of infection and the highest level of AIDS treatment in the Caribbean region. Cuba’s AIDS infection rate is less than 0.3%, one of the smallest in the world, compared to an average of 6-8% in surrounding Caribbean countries. However, the sanitarium program has received heated international criticism in the name of freedom and human rights. One author writes that Cuba’s AIDS program is the most successful and at the same time most hated AIDS program in the world (Burr 1997). Nancy Scheper is one of the few anthropologists who was impressed with the success of Dr. Avila’s program. In some points in her correspondence, she seems to imply that these techniques could be emulated in the United States and elsewhere (De Gordon 1993). She was allowed two chaperoned tours of the sanitarium of Santiago de Las Vegas while it was still operating. She said she left both times with conflicting views: on one hand a forcible quarantine was a violation of human rights, but on the other, the sanitariums were extremely successful (Scheper 1993). In one article, she is quoted saying that AIDS immediately being seen as a human rights issue in first world nations may have prevented the identification of risk groups and areas. She quotes Cuba’s low pediatric AIDS cases compared to the United states and that only 9 Cubans were infected through blood transfusions, compared to thousands in each France and Brazil. Another anthropologist calls Scheper by name and strongly argues against Cuba’s methods due to the involvement of the Cuban government. He discussed how the Cuban regime considers AIDS a state security issue and therefore keep the true statistics confidential (De Gordon 1993).
One difficulty in writing this paper was the varying information and use of statistics throughout the articles I referenced. Many peer reviewed articles and even books all state different numbers but reference the same sources. Dates have also been hard to track, for instance, two sources state the first case of HIV in Cuba was in 1981 and two others state it was in 1985. The origin of this first case is also contested, with some authors saying the first HIV internationalista came from Mozambique and others saying Angola. A more extreme example of these inconsistencies is the information surrounding the mother to child transmission of HIV, which was listed as a main goal for the National AIDS Commission. Cuba was the first country in the world to eliminate (eliminate according to the World Health Organization’s standards) the transmission of HIV of from mother to child. According to what article is being read, this statistic can be very misleading. When reading the cited case study about the management of HIV/AIDS in Cuba, there is only mention of the successful statistic that Cuba was the first country to eliminate mother to child transmission of HIV. In the other sources, there are four mentions of abortion playing a role in this particular statistic. Two of the articles merely say there was access to abortion as a birth control (Scheper:1993, Hansen 2001). However, two more state specifically that women who were HIV positive and became pregnant aborted their pregnancies. One maintains that women are advised to have abortions, “The women are under no pressure to follow the advisory, though in the past, most HIV positive pregnant women had abortions” (Parameswaran 2004:8). The last insinuates coercion stating abortions are “strongly recommended” and that “about 98% of HIV-seropositive mothers have elected to terminate their pregnancies” (Granich 1995:4). Today, new medications combined with Cesarean sections severely minimize the chance of mothers passing HIV to their children so rates have gone down in most first world countries. However, Granich’s statistic combined with the phrase “strongly recommended” might imply that there was no option for these women.
The root of the difficulty writing this paper lies in the fact that no independent researchers were allowed to visit the sanitariums unsupervised. Every visit was chaperoned by doctors or Ministry of Public Health staff and therefore many researchers are weary of the data collected. Planned visits are easy to manipulate; the food could be better, the air conditioning could be turned on, the building could have just been cleaned, there are limitless ways to modify a planned visit to favor one side of a story. Another reason for the lack of data could just be that researchers were too scared to go. With the US embargo and Cuban isolationist policy, visiting would have been difficult. Another possible reason was the topic itself. There are many articles asking anthropologists to become more involved with HIV/AIDS. AIDS was labeled an ‘unclean’ research not only because usually transmission involves unclean acts, but because originally AIDS meant researching minorities. Herdt writes “AIDS research is an ‘unclean’ scientific research which in certain instances can stigmatize its researchers” (Herdt 1987:1). Regardless of the reason, having more statistics and less circulating data would have made writing this paper much easier.
Overall, I enjoyed writing this paper. It was difficult at times to sort through the varying data and statistics, but I’m always up for a challenge. If I had had more time and space I would have liked to do a comparison between Cuba’s response to HIV and a wealthier nation like the United States. Comparing the two responses would have been very interesting, especially since the two countries’ political climates are so different. I also think the lifting of the US embargo on Cuba will have very interesting effects. In his interview, Dr. Avila talked about how the embargo has resulted in chronic shortages of medicine and medical equipment (Fink 2003:3). With the embargo now lifted, hopefully this will mean better access to medicine, medical equipment and basic medical supplies.