HIV in Cuba:
Prevention of Mother-to-Child Transmission
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International Public Health Pitfalls and Economic Arguments:
The Fight Against AIDS in Cuba and Haiti

Cardiovascular Disease and Associated Risk Factors in Cuba:
Prospects for Prevention and Control

 

INTERNATIONAL VOICES

International Public Health Pitfalls and Economic Arguments:
The Fight Against AIDS in Cuba and Haiti

Arachu Castro, PhD, MPH and Paul Farmer, MD, PhD*

From Rethinking ‘the Public’ in Public Health: Neoliberalism, Structural Violence, and Epidemics of Inequality in Latin America, Working Papers of the Center for Iberian and Latin American Studies (CILAS). San Diego: University of California at San Diego (2005, in press).

We use the lens of AIDS trajectories in Haiti and Cuba to challenge currently predominant ideologies in international public health, including over-emphasis on cost-effectiveness, as criteria to allocate resources. In Haiti, where AIDS is the number one cause of all adult deaths, the prevalence of HIV is the highest in the Americas; in Cuba, with the lowest prevalence in the Americas, the government provides comprehensive care for all AIDS patients despite a deepening economic crisis. The two distinct stories mirror the nations’ divergent paths to economic development. Instead of focusing on standard economic measures, the health of the poor should be considered the most telling public policy and international public health outcome.

A dramatic redefinition of health priorities now holds increasing sway in Latin America, where assessing public health has become a treacherous exercise. This is not because it is impossible to evaluate the state of the region’s health, nor is it because the admittedly enormous variation, both across and within nations, leads to analytic impasse. To assess the health of a nation is treacherous because of the ideological minefields one now has to traverse when commenting on public health in Latin America. In the past, such assessments may have been easier, and not because public health was then a more robust undertaking. Rather, there was previously a consensus that the health of the poor was a cardinal indicator of how well the stewards of the public’s well-being were doing their job. At this point, however, it is unclear even who the stewards of public health really are. Rudolph Virchow has been called the father of social medicine, and it was he who dubbed doctors “the natural attorneys of the poor.” Doctors were supposed to defend the poor because the impact of their social condition – poverty was embodied as preventable or treatable sickness. Virchow also quantified this position in quite graphic modern-day epidemiological terms: “Medical statistics will be our standard of measurement; we will weigh life for life and see where the dead lie thicker, among the workers or among the privileged” (quoted in Rosen 1974:182, from Virchow’s Medicinische Reform; see also Eisenberg 1984).

A critical examination must also be made of an even more troubling quantification - the increasing weight assigned to economic arguments in assessing approaches to the AIDS pandemic - and the unhealthy outcomes that these arguments engender in poor countries. The impact of contrasting economic arguments and the impending need for challenging some of the current predominant ideologies in international public health are undeniably exposed through the exploration of the respective AIDS trajectories in Haiti and Cuba.

Cost-Effectiveness and the Health of the Poor

As public health has become a larger enterprise, it has defined a turf of its own; as nation-states have come into being in Latin America, they have defined national public-health agendas, increasingly with the assistance of experts from international institutions. The “welfare state” that we think of as having been progressively built up, from the 1930s to the beginning of its decay in the 1980s, barely got a start in Latin America before debt and the agenda setting of First World economic advisers attempted to terminate the welfare state as a public responsibility. The health of the poor is now deemed less important than the cost containment of public health services, and governments too often push to minimize the healthcare drain on national budgets increasingly dedicated to the supposedly higher goals of debt service and privatization (see Kim, Millen, Irwin, and Gershman 2000). Several recent years have noted the deadly consequences of the shift in priorities from the epidemiology of disease to economic arguments that promote the nonprovision of services termed “not cost-effective” without necessarily offering alternatives for those who need those services but are too poor to afford them (see Kim, Shakow, Castro, Vanderwerker, and Farmer 2003).

Those struggling to promote the health of the poor are now in the defensive position of having to show that proposed interventions are both effective and inexpensive, regardless of the gravity of the health problem in question. Aside from local ministries of health, the largest financiers of public health in Latin America, except for Cuba, include the international financial institutions, such as the World Bank and, less directly, the International Monetary Fund. In some regards, this makes sense, given the undeniable association between economics and health. But there is a dark side to the new accounting: such sources place funding for public health within a framework developed by economists working within a paradigm in which market forces alone are expected to solve health and social problems - a paradigm which is one of the ideological minefields. As efforts are made to determine whether or not an intervention is “cost-effective,” the destitute sick are often left out altogether.

In attempting to address the AIDS pandemic, the region of Latin America and the Caribbean now faces a formidable challenge (Castro et al. 2003). At the present time, 1.5 million people in Central and South America and at least 420,000 in the Caribbean are already living with HIV/AIDS (UNAIDS 2002a). The Caribbean, with an adult HIV prevalence of 2.2 percent (UNAIDS 2001), has the second highest rate of HIV infection in the world (UNAIDS 2002a), second only to sub-Saharan Africa. Prevalence rates vary from country to country: in Haiti, adult prevalence of HIV exceeds 6 percent; in the Dominican Republic it is 2.5 percent; in Jamaica it is 1.2 percent; while in Cuba the prevalence is less than 0.05 percent (UNAIDS 2002b).

To date, the response of the affluent countries and their institutions to this crisis - from aid agencies, nongovernmental organizations (NGOs), and the pharmaceutical industry - has been insufficient. The death toll and increasing HIV incidence in countries highly dependent on foreign aid provide the most eloquent rebuke to economically driven assessments. Until the first disbursements were made by the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2003, the quasi-totality of AIDS assistance to the heavily burdened countries had consisted of the promotion of education and condom distribution to prevent HIV transmission. Yet, many of those at greatest risk already know that HIV is a sexually transmitted pathogen and that condoms could prevent transmission. In Haiti, over 97 percent of the population knows of the existence of AIDS, and 62 percent of women and 81 percent of men know at least one way to prevent infection (Cayemittes, Placide, Barrère, Mariko, and Sévère 2001). Their risk stems less from ignorance and more from the structural violence that millions of people endure in Latin America as a result of historic, political, and economic processes (see Farmer 1999, 2003a; Castro 2003).

Aid agencies have increasingly relied on economic evaluation analyses to allocate resources. Current economic evaluation approaches to public health include cost-benefit and cost-effectiveness analyses, both of which rely more on projections of the outcomes derived from investments in specific health interventions than on empirical data. Still, they inform budgeting and financial planning, help assess the affordability of interventions, and help identify areas for improving efficiency of delivery of services and cost savings (Gold et al. 1996; Murray and Lopez 1996; Holtgrave 1998).

With its many inherent underlying assumptions, the usefulness of economic analysis as a tool for policy makers and funders has been grossly overstated - creating another ideological minefield (see Moatti et al. 2003). By uncritically accepting that resources are limited - one of the fundamental assumptions of economics - and by advocating the use of decision tools designed to measure specific interventions rather than a comprehensive assessment of an entire health program, these approaches have curtailed potential investment in timely AIDS prevention and care in Haiti. Very few economic evaluations have sought to move beyond a narrow definition of outcomes or to reformulate the mathematical equations to include other outcomes such as lower risk of transmission (Blower and Farmer 2003) or the social benefits derived from providing appropriate treatment to people living with HIV/AIDS, as it happens in Cuba. Such social benefits have an impact at the household, community, and national level by helping patients resume work and take care of children and relatives.

The omission of these social variables should not be overlooked given the threat the AIDS pandemic poses to economic development. In addition to the grave effects on the down-spiraling GDPs of the most hardest hit countries, AIDS in the Americas could result in the creation of a “missing generation,” as has already occurred in parts of sub-Saharan Africa; in these areas, much of the middle- or working-age population has died or will die from the disease, leaving children (often orphans) and the elderly as survivors. If social variables are taken into account in the cost-effectiveness analysis of health interventions, providing comprehensive AIDS treatment would be more “cost-effective” than current medical and public health literature suggests.

Health in the Pearls of the Antilles

Neighboring islands Cuba and Haiti both claim to be “the Pearl of the Antilles,” owing to the wealth they procured, under colonial rule, to Spain and France respectively. Yet, as Cuba’s José Martí noted over a century ago, “Haiti is a land as peculiar as notable, and in its roots and constitution so different from Cuba, that only pure ignorance can find between them a reason for comparison, or argue with one with respect to the other” (1894:51). It is with fascination and a bit of dread that we turned to comparing public health and AIDS in these two countries, and the impact of the logic of cost-effectiveness in such diverse settings.

Haiti has the highest maternal and infant mortality rate in the Americas; Cuba, the lowest. The leading killers of young adults in Haiti are AIDS and tuberculosis; Cuba has the lowest prevalence of HIV in the Americas and remarkably little tuberculosis (PAHO 2002a). The Human Development Index 2003 ranked Haiti 150 out of 175 countries; Cuba ranked 52 (UNDP 2003). Haiti is by all conventional criteria the poorest country in the Americas and one of the poorest in the world: per capita gross domestic product was US$460 in 2001 (UNDP 2003); 67 percent of the population lives in poverty (PAHO 2003), unemployment exceeds 70 percent, and fewer than one in 50 Haitians have regular employment (World Bank 1997). Political violence, among other afflictions of poverty, is endemic. Around 40 percent of the Haitian population has no access to health care; approximately 20 percent of the population uses the public sector, 20 percent the mixed public-private sector, and 20 percent the private sector (based on PAHO 2002a). In Cuba, in contrast, GDP per capita in 2000 was estimated at US $1,475 (PAHO 2002a:198), unemployment in 1998 at 7 percent (UNDP 2000), and access to public health care at 100 percent (PAHO 2002a).

Health conditions in Haiti are among the worst in the world. All of Haiti’s public health indices are poor, and it is not coincidental that Haiti has the highest incidence of HIV in the Americas. As elsewhere in the world, infant mortality rates in Haiti fell slowly but steadily over the course of the past few decades. More recently some of these trends have been reversed and infant mortality now stands at 80.3 per 1,000 live births. Infant mortality in Haiti has actually risen since 1996, when it was 73.8 per 1,000 live births; PAHO attributes this rise to increasing poverty, the deterioration of the health system, and AIDS (PAHO 2002a:338). Maternal mortality rates are appalling. Even the low-end estimates (523 per 100,000 live births) are the worst in Latin America (PAHO 2002a), and the only community-based survey, conducted around the town of Jacmel in southern Haiti in the 1980s, pegged the figure at 1,400 per 100,000 live births (Jean-Louis 1989). As for food and water, according to the United Nations Food and Agriculture Organization (FAO), Haiti is the third hungriest country in the world (FAO 2000). The water story is even worse: in a recently developed “water poverty index,” Haiti was ranked in 147th place out of 147 countries surveyed (Sullivan, Meigh, and Fediw 2002).

AIDS is a serious problem in Haiti. With an estimated 250,000 people living with HIV/AIDS (Global Fund 2002b), Haiti is perhaps the only country in the Americas in which AIDS stands as the number-one cause of all adult deaths (PAHO 2002a). Haiti was the first country after the United States to report AIDS cases. Amid a great deal of controversy over the origin of HIV in the Americas, researchers now believe that HIV spread to Haiti through contact with North Americans, and not vice versa. Male commercial sex workers, catering to a largely North American clientele, played a large role in the spread of HIV within Haiti and the rest of the Caribbean region (Farmer 1992). The Haitian AIDS epidemic has been described as “generalized” since it affects women as much as or more than men (Pape 2000), is not confined to any clearly bounded groups, and has spread from urban areas to the farthest reaches of rural Haiti. HIV kills 30,000 Haitians each year, with an estimated cumulative number of 196,000 deaths and 200,000 orphans (UNAIDS 2002b; Global Fund 2002a). HIV has also aggravated an already severe tuberculosis epidemic. In Haiti, between 15 to 45 percent of hospitalized patients in urban areas are infected with HIV; in TB sanatoria, the proportion is more than 50 percent (Pape 2000). It is estimated that around 2,000 people with AIDS in Haiti are on HAART, both in rural Central Plateau and in Port-au-Prince; the number is expected to increase (Global Fund 2004b).

In 1989, soon after AIDS was declared a priority disease in Haiti, the National Commission to Fight AIDS was appointed, while the AIDS National Bureau was created with full-time personnel from the Ministry of Health (Global Fund 2002a). This bureau was operational until the coup d’état of 1991, when all foreign aid stopped (Pape 2000). While in 1991 the allocation of the Ministry of Health was US$6 million, after the resumption of foreign aid between the two embargoes the budget increased considerably, going up to US$57 million in 1999 - which represents about 10.5 percent of the public budget and between 0.8 and 1 percent of the GDP.  The majority of the budget of the Ministry of Health - 69 percent in 1996–1997 depended largely on foreign aid (PAHO 2002a).

In 1998, the Haitian Ministry of Health recognized health as a fundamental human right, while acknowledging the difficulties with meeting that goal due to scarce human and financial resources (PAHO 2002a). Notwithstanding these constraints, the AIDS National Bureau was reorganized in 2001, when the president of Haiti launched the five-year National Strategic Plan exercise (Global Fund 2002a). One year earlier, the Bank of Haiti had estimated that the country produced the same amount of goods and services as it had in 1980, while the population had increased by 75 percent over the same period (Banque de la République d’Haïti 2000). With such a devolving economy, an international aid embargo, and the majority of international public health experts claiming that comprehensive AIDS care was unsustainable and not cost-effective in resource-poor settings, what was the government of Haiti left to do? Was the existing political will enough to woo external resources to fight AIDS?

One could not find a starker contrast within Latin America as that between Haiti and it’s second-closest neighbor, Cuba. Like Haiti, Cuba has known major economic disruption in the past decade. In 1991, after losing 85 percent of its foreign trade as a result of the dismantling of the former Soviet Union (Economic Commission for Latin America and the Caribbean [ECLAC] 1997 [2000], 2001), Cuba entered an economic crisis, officially named the Special Period in the Time of Peace. The dependency on the Soviet Union had provided Cuba with a buffer against the U.S. economic blockade of the island that began in 1961. Although Cuba benefited greatly from its economic ties with the Soviet Union, this dependency proved disastrous starting in 1989; no longer able to import petroleum products, foodstuffs, or medicines and distribute them at heavily subsidized prices, Cuba’s economy spiraled into crisis. In addition, in 1992, the U.S. Congress passed the Cuban Democracy Act, which restricts the sale of food, medicines, raw materials, and medical equipment to Cuba, and penalizes third countries that deliver drugs and other goods to this Caribbean island. These newly imposed restrictions and the loss of foreign currency resulted in significant shortages of drugs and medical equipment (Castro, Togores, and Barberia 2003). This contraction was as severe as that faced by any Latin American economy.

So what about the impact of such seismic rumblings on the health of the Cuban poor? Although much is made of the harm done by the U.S. embargo to Cuban medicine, the Cuban people remain healthy. This is due in large part to the structure of Cuba’s economic, social, and public health systems (see Feinsilver 1993; Chomsky 2000; Barberia and Castro 2003). In addition, state control of the economy helped distribute the impact of the crisis far more equitably, preventing it from striking hardest at the poor - something that would have been impossible in what others would consider a “model,” and therefore capitalist, developing country economy.

Indicators such as infant mortality have actually continued to decline: in 1985 infant mortality was 15 per 1,000 live births, in 1990 it was 10.7, in 1995 it was 9.4, and in 2000 it was 7.2 (Ministerio de Salud Pública [MINSAP] 2001). World Bank data records Cuba’s infant mortality as 6 per 1,000 live births, far below the 27 per 1,000 live births registered for Latin America and the Caribbean (World Bank 2003b). In fact, there was little impact on overall morbidity and mortality trends during the Special Period, except for a rise in infectious diseases that had been deemed under control, such as tuberculosis (Marrero, Caminero, Rodríguez, and Billo 2000). One reason for such minimal effects - and there are no doubt several - is that health spending was increased during the economic crisis in order to shield the vulnerable from adverse health outcomes. Between 1990 and 1997, health spending rose in local currency in both absolute and relative terms, growing from 6.6 to 10.9 percent of federal outlays (Ministerio de Finanzas y Precios 1998).

Despite high prevalence rates of HIV in the Caribbean, as of the end of 2002, Cuba had registered 4,517 HIV-positive cases since the beginning of the pandemic - of the 3,413 alive, 928 had been diagnosed with AIDS at that date (Pérez-Ávila 2003) - and continues to boast an HIV-prevalence rate below 0.05 percent (UNAIDS 2002a). In 1983, although the etiology of the newly emerged disease was still unknown, Cuba created a National AIDS Commission, which recommended the costly destruction of its imported blood products and prohibited importation of new products. The National AIDS Commission, building on the already well-developed primary health care system, created an epidemiological surveillance system in each hospital to detect clinical manifestations of AIDS (Pérez-Ávila, Peña-Torres, Joanes-Fiol, Lantero-Abreu, and Arazoza-Rodríguez 1996). At the end of 1985, the first Cuban HIV-positive case was diagnosed at the Institute of Tropical Medicine (IPK) in Havana. The patient had served as an internacionalista (international aid worker) in Mozambique until 1977; his wife also tested positive. When the IPK reported these first two cases to the vice minister of epidemiology, the Cuban government assigned US$2 million to import 34 ELISA kits that would allow them to conduct 750,000 HIV tests - an average of 400,000 blood donations per year (Pérez-Ávila 2003, personal communication). The imported ELISA kits were distributed throughout all the blood banks and centers for hygiene and epidemiology of the country; by 1986, all blood donations were screened for HIV.

In 1986, the sexual contacts of people diagnosed with HIV were enrolled in the Partner Notification Program and tested for HIV every three months for a period of one year after the last sexual contact with the HIV-positive patient (Hsieh, Chen, Lee, and de Arazoza 2001). While from 1986 until 1993 Cuba relied on controversial HIV sanatoria to contain the epidemic, this strategy has shifted to a combination of in-patient and ambulatory care (Castro, Farmer, and Barberia 2002). Cuba is one of the few developing countries to guarantee comprehensive health care and treatment for all people living with HIV/AIDS. Since 1997, pregnant women who have HIV receive AZT and breastmilk substitutes to prevent mother-to-child transmission of the virus (González-Núñez, Díaz-Jidy, and Pérez-Ávila 2000). Since 2001, all Cuban HIV-positive patients who meet certain clinical criteria are eligible for HAART, and, as of June 2004, there are 1,533 AIDS patients enrolled (Pérez-Ávila 2004, personal communication). Their treatment consists of three domestically produced generic antiretrovirals, which include several reverse transcriptase inhibitors and one protease inhibitor. Since 2001, there has been a decrease in the number of deaths from AIDS and in the incidence of opportunistic infections related to HIV/AIDS. The number of patients hospitalized at the IPK has dropped - from 90 per month in 2000 to 12 per month in 2001 - even though HIV incidence has increased (Pérez-Ávila 2002, personal communication).

Life and Death and the Logic of Cost-Effectiveness

What conclusions can be drawn from these comparisons? Which countries, other than Cuba, would have invested US$2 million to contain the spread of HIV when only two cases had been diagnosed? The Cuban experience with AIDS is a rebuke to those who place overarching emphasis on cost-effectiveness in setting public health priorities. It also supports the compelling argument that comprehensive AIDS care is “sustainable” in the hardest-hit communities and demonstrates that care is “cost-effective” and a “ranking priority” in the face of other competing demands. Some health economists suggest that a life-saving intervention that costs between two to three times the gross national product (GNP) per year-of-life saved represents a reasonable expenditure (Garber 2000). Even by this crude calculus (see Moatti et al. 2003:254–255 for its critique), a three-drug HAART regimen at generic prices would prove a sound investment by any criteria, even in Haiti, as long as drugs are used correctly. Still, when Partners In Health sought funding for expansion of a pilot project in rural Haiti (Farmer, Léandre, Mukherjee, Claude, et al. 2001) from a number of international agencies charged with responding to AIDS, all declined to support this effort on the grounds that the drug costs were too high to meet so-called sustainability criteria, given the profound poverty of Haiti. Pharmaceutical companies were approached for contributions or concessional prices, but they referred Partners In Health back to the same international agencies that had already termed the project unsustainable. Ironically, a survey conducted by the Pan American Health Organization in 2001 showed that some antiretrovirals were more expensive in Haiti than in the United States (PAHO 2002b).

It is, in fact, not the treatment of the destitute sick that is unsustainable, but rather the ever-widening global outcome gap that prohibits the fruits of science from reaching those most in need of them. The destitute sick remind us that sacrosanct market mechanisms will not serve the interests of global health equity. It is difficult to support the assertion, widespread in international financial institutions, that the neoliberal economic policies now in favor will ever serve the interests of those living with HIV. If the goal is to heal or to ease the suffering of the poor, there are enormous obstacles erected in the way of financing what was once believed to be a public good (see Smith, Beaglehole, Woodward, and Drager 2003).

Although the ideological underpinnings of the various approaches to public health are the subject of medical anthropological inquiry, actual outcomes such as morbidity and mortality rates need to remain at the core of these analyses. Of course, the major debate in health and social policy is over which outcomes are most vital. For economists, such measures as GNP and external debt are key indices (which are ideologically freighted subjects in and of themselves). For education experts, literacy rates is a key measure. The human rights community, interestingly, almost always narrows its focus to privilege rights of expression and representation while excluding social and economic rights - an omission that should trouble physicians, who need supplies of tangible goods, the very tools of their trade, before they can go to work (Farmer 2003a). Unless the Latin American poor are accorded some right to health care, water, food, and education, their rights will be violated in precisely the ways manifest in Haiti: their lives will be short, desperate, and unfree.

And so we return, as always, to the health of the poor as the most telling social-policy outcome. Because we believe that assessing the health of the poor is the best way to assess public health in Latin America, it is wise to avoid confident claims regarding “cost-effectiveness” and “appropriate technology.” Cuba has introduced sophisticated assays of viral load costing a small fraction of what tests cost in the United States; it has manufactured many antiretrovirals locally. “It is no accident that the country that disproves the assumptions behind the argument, Cuba, is virtually always left out of mainstream analyses that attempt to defend neoliberal reforms” (Chomsky 2000:332). Actually, Cuba’s experience leads us to reconsider the economics of intervention in slowing the spread of HIV and reducing the death toll.

In Haiti, where AIDS is the reason for plummeting life expectancies and for increasing numbers of orphans, we discern fairly overt obstructionism to the use of HAART. Leaving aside all moral arguments, any economic logic that justifies as acceptable the orphaning of children is unlikely to be sound, since the long term cost to society, though difficult to tabulate, is far higher than the cost of prolonging parents’ lives so that they can raise their own children. Furthermore, AIDS treatment causes a dramatic drop not only in mortality (Marins et al. 2003) but also in the number of opportunistic infections and the consequent number of hospital admissions (Gebo, Chaisson, Folkemer, Bartlett, and Moore 1999). HAART has already been declared cost-effective in Europe, North America, and even Brazil, where HIV has become, for many, a chronic infection (Freedberg et al. 2000).

We keep hearing that we live in “a time of limited resources.” But how often do anthropologists, physicians, or public health specialists challenge this slogan? The wealth of the world has not dried up; it has simply become unavailable to those who need it most. By questioning these unfounded economic assumptions, medical anthropologists can contribute to rethinking the long-standing public health paradigms that curtail access to health care for the poor.  In this time of record profits for many industries - especially the research-based pharmaceutical industry - and dazzling individual fortunes, is it unthinkable that we should spread the wealth? If the health of the poor is the yardstick by which our public health efforts in Latin America are judged, we will have a lot of explaining to do when history sits to consider our case.

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*Based on Paul Farmer Paul and Arachu Castro (2004), “Pearls of the Antilles? Public Health in Haiti and Cuba,” in Unhealthy Health Policy: A Critical Anthropological Examination, Edited by Arachu Castro and Merrill Singer, Walnut Creek: Altamira Press, pp. 3-28.

 
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