Cuba is a land of contrasts.   A totalitarian regime ruling over a friendly, open people.  Extreme poverty by American standards, coupled with effective public health efforts.  An educated public that often cannot put its education to use.  Cuba: A mix of low technology such as cars from the 1950’s, alongside modern, efficient pharmaceutical development operations.  Americans (at least non-Cuban Americans) have ambivalent feelings towards Cuba.  We know it is the last bastion of Communism in the western hemisphere in a world which has seen the rapid decline and dissolution of communist states.  Americans cannot travel there without special permission, but those who do return with only positive things to say about the Cuban people.  Our stance towards Cuba seems to be a vestigial function of the historical Cold War, the last reflection of our fear of the former Soviet Union.   I’m not sure how I feel about Cuba as a political entity, but the purpose of my visit was to examine their efforts at combatting HIV/AIDS, and I feel it would be useful to share some of my qualitative impressions.

In Cuba, I visited the National School of Public Health, The Finlay Vaccine Institute, The International School of Medicine (the ELAM), and Policlinicas (ostensibly community health centers).  Everywhere we went, the public health officials (who I am confident were vetted before being allowed to speak with us, to assure that they conformed adequately to the party line) were nonetheless passionate, educated, and expressed strong commitment to the well-being of their fellow Cubans.  We know that a variety of social factors affect public health, and Cuba presents an interesting case study – divorce rates are high.  Teenage pregnancy rates are low.  Literacy rates are stunningly high at around 90%.  Individuals are officially taught that the best time for pregnancy is between the ages of 25-35.  This means Cubans can all read the prevention materials (low literacy being a problem with prevention efforts among other populations) and can get out of bad marriages without stigma if they need to.  While I don’t want to suggest that Cuba is some sort of utopian paradise (far from it, with an oppressive government and crumbling infrastructure), but in these few factors which have a major impact on public health, they certainly seem to be ahead of the curve.

During my visit to the National Center for the Prevention of HIV and STDs (which opened in 1998) the value of pride, solidarity and collectivism were repeatedly expressed. These values are so often reiterated, one is surprised not to see the classic Soviet propaganda posters of the heavily muscled female factory worker that is the communist equivalent of Rosie the Riveter.  But perhaps there is something to the values as expressed by the public health community. There was enormous pride in the low HIV incidence and prevalence rate (in fact, astonishingly low for the Caribbean), yet apparent disinterest in actual demographic and incidence figures. Since the population is particularly well educated, this disinterest in statistical data was particularly puzzling.  Whether this is a function of relative success at prevention of HIV/AIDS, or a deliberate obfuscation is not entirely clear.  The Cuban health professionals were all agreeable, answering our questions freely even though at times we (the largely American group of public health professionals) may have come off as a bit rude. For example, the medical doctors in my group grilled an HIV prevention educator about incidence numbers, openly questioning how these numbers were derived and why the data was not published in academic journals. I laughed out loud a couple of times because it seemed that those in my group did not quite understand the differences in cultural values and public health systems, and seemed oblivious to the fact that Cubans are not necessarily as free to answer questions as their American colleagues, unless they have no strong objection to winding up in some sort of secret prison being interrogated in a most unpleasant manner.  The public health system in Cuba is supposedly for the people, and this seems reflected in its arrangement. The public health system in the US claims to be for the people, but one sometimes wonders if it is more designed to support the insurance industry and further the careers of public health academics and professionals. In Cuba, the academic and health fields are not tenure-based, therefore the focus can be on actually promoting public health in a practical way and on effective education.  In the U.S., researchers, typically affiliated with universities may have an interest in promoting public health, but it is twisted up in the rat race for tenure that demands publication in ludicrous amount in journals nobody cares about to establish “scholarly” credentials.  Professors are paid little enough as is, and higher salaries are dependent on tenure, therefore, unless an academic is not particularly fond of, well, eating or having a roof over their head, they’ll play the game and publish like it’s going out of style.  Plus, it doesn’t hurt the ego, when the graduate students fawn all over you because you’ve gotten a few articles in journals that they themselves are busy sending articles to (see “Rock Starts in a Small Pond”).  Is it that we value individual accomplishment more than Cuban health professionals, or is it a sign that the structure of our public health system prioritizes individual accomplishment over actual public health?  Just asking.  Don’t start calling me a commie.  You know you were thinking it.

Based on the question and answer period we were afforded at the National Center for Prevention, below are some qualitative observations of Cuba’s health care system as it pertains to HIV:

· The value of solidarity is evident in the realm of HIV prevention. In Cuba they main use two tactics to address HIV: structural level interventions (i.e. social marketing) and community level (peer led, popular opinion leader) interventions.  Both of those tactics require establishment of solidarity (or a sense of togetherness) to reach a wide population. In the US structural interventions have lagged behind.

· In terms of social marketing campaigns, Cuba uses the tactic of appealing to collectivist values (or in their case solidarity) and a sense of national pride. For example, one tag line was “todos nos protegemos” (translation: “we all protect ourselves”). Another campaign’s tag line was “seguros y audaces como los campeones, si lo usas ganas” (safe and bold like the champions, if you use it you win)–with multicolor condoms in the shape of Olympic rings, playing up national pride. It’s nice to think that wearing a condom can help some feel that they are champions.

· HIV appears to still be stigmatized in Cuba. Interestingly, a great sense of pride was manifested at the Prevention Center. However, while I was at other public health venues, there was barely a mention of the low HIV incidence and prevalence rates. There was much more of a focus on the low childhood mortality rates along with the 13 Cuban-produced vaccines (which are used internationally).  So, in regards to stigma, Cuba manifests an attitude not much different than other Caribbean and Latino populations.

· Many of the social marketing campaigns target the general public. However, one campaign stated “homosexualidad no es el peligro” (Homosexuality is not the danger) which shows an attempt by the government to engage in efforts to de-stigmatize homosexuality. This in turn serves as an interesting comparison to current debates surrounding social marketing campaigns by the New York City Department of Health (many argue these serve to stigmatize gay men) and campaigns such as the one in Los Angeles which states “HIV is a gay disease.”

· The Legendary Dr. Jorge Pérez, who at one point directed the “sanatoriums”, came to talk to us and argued that Cuba’s low incidence rate is due to the fact they acted early and treated AIDS as a public health emergency from the outset. Cuba, according to Dr. Perez, was one of first countries to take AIDS seriously as a problem. Accordingly, these were their immediate actions:

o Patients were brought to sanatoriums to train the family & in order to have multidimensional care teams

o Cubans who had visited Africa were tested, as were all pregnant women (hmm, who is doing that now?)

o HIV positive women were given drugs to prevent perinatal transmission and babies were delivered by caesarian.

o Blood banks were  emptied out and started anew.

o The first few years of the epidemic they supposedly tested 3.5 million people. In the US, we now have major testing initiatives.

Cuba serves as an interesting point of contrast with the United States regarding HIV.  Cuba takes a decidedly public health perspective, while the United States associated HIV with issues of civil rights, as the most affected populations were battling both the disease as well as civil rights issues at the same time . While Cuba’s public health perspective might seem to be cold, it is actually infused with cultural values of solidarity and great sense of pride. The United States has at times been more emotionally tied to anger, stigma, and segmentation of populations. Unfortunately, we don’t get to read much about Cuba’s successes or challenges since they are not working in a system of academic capitalism.  Here’s hoping that with time, we each progress further in the eradication of HIV/AIDS and that we can break bread together and discuss how we each successfully battled the disease in a world where it no longer plagues us.