Cuba: A poster child?

Cuba has an interesting method of dealing with HIV infections. Despite international protests, in 1986 Cuba initiated a quarantine policy that kept people with HIV apart from the general public in a sanatorium.

While now the forced quarantine has been lifted, people who test positive for HIV are required to take a three month course on living with HIV and on the importance of protecting others from exposure. Cuba has been viewed as the "poster child of prevention" both having reduced the spread of HIV and gained control of the epidemic, with one of the lowest HIV incidence rates in the world. Yet at what cost? A fine line exists between too much government intervention affecting privacy and good public health, yet where do we draw the line? Whose rights are more important, the individual rights or community rights?

D'Adesky writes about "Cheo", an HIV positive gay male who was diagnosed with the disease in 1993. For two years the government tried to pressure him into living at the Sanatorium, at one point they even threatened arrest. The attack on the personal freedoms of Cheo is not an isolated case. Other PLHIV face the same constraints in Cuba. But as the statistics support, this method of isolation and mandatory education programs has been instrumental in quelling the epidemic in Cuba. By limited the freedoms of a few (or more specifically 1,000 people), Cuba has protected the rest of its 11.5 million residents so that they are relatively more healthy.

This concept of restricting choices is not limited to Cuba. We see it here in the U.S. with increasing restrictions on smoking. In an increasing number of states, smokers are no longer allowed to smoke in public places such as bars, restaurants or the work place. These regulations are designed to improve the health of the greater community. Now not being able to light up a cigarette in your favorite neighborhood bar is slightly different than being forced to live in a sanatorium and have your every move monitored, but it shows that when making public health choices we most often side with the community.

One interesting note about Cuba is that Cubans put the responsibility of containing the AIDS epidemic on those with HIV, through education and by creating a code moral responsibility. And this approach appears to be working. Out of the 1,000 or so people that stayed at the sanatorium very few have infected others. The current climate of much of the western world is that we have a right to health care, or a right to education, without placing any sort of behavioral or moral obligations. Should people have access to a triple by-pass surgery if they continue to jeopardize their health immediately afterwards by eating a fast-food diet? I think Cuba is going in the right direction by not only educating people about how HIV is transmitted but also by conducting a kind of moral education as well.

Another thought that came to mind while reading this chapter was have the luxurious living conditions in the sanatorium actually created a perverse incentive to become infected with HIV? Dr. Jorge Perez Avila, who runs the national HIV treatment program, describes the good living conditions of the sanatorium. "They have a house, air conditioner, color TV, 100% of their salary and a diet very high in calories and rich in protein. No one else has that much." In fact when Cuba lifted the quarantine in 1993, only 10% of residents opted to leave when offered a chance. Given the now chronic nature of HIV since the improvements in ARVs would people be willing to trade their health for some air conditioning and local soap opera on TV?

At this point, this doesn't seem like a realistic concern, but as treatment continues to improve and class divides become exacerbated, we must be aware of the incentives the current treatment of PLHIVs is creating. I am by no means saying that we should start treating PLHIV poorly or send everyone to the streets, but I feel that isolating PLHIV and giving them certain privileges that others don't enjoy will create an "us" vs. "them" mentality that could provoke further stigma amongst the general population as well as encourage poorer populations to contract the disease.