Cuba: "All for one, and One for all"

It is true that people should not be victims of discrimination because of their illneses. It is also true that, as a community, we have to look out for each other in order to advance as a whole society. Cuba had a good idea about isolating those who were HIV positive, especially because they virus, at the time, was not fully understood. When the first HIV cases were known, people had no idea how it could be transmitted. Unfortunately, decades later, there are millions of people do not understand how HIV can be transmitted from one individual to another. People who do have HIV are victims of discrimination around the world. Although it is illega, there are thousands of individuals who get fired from their jobs because of their HIV status. Also, these people have a difficult time finding life partners because people fear contracting HIV. Whenever people find out someone is HIV positive, they treat them with fear and alienation. People who have HIV already leave in some kind of alienation, looking for other people who can share their life stories and experiences. Wouldn't it be better, to live in a community where you would not be a victim of discrimination, and people around you understood your hadrships? If everyone in the world knew exactly how HIV is transmitted and if HIV-positive people were careful enough to not spread HIV then we would have a different story.

Learning from Cuba

The mandatory quarantining of HIV-positive Cubans is indeed an obvious violation of human rights—though, as Yasmin and Yahaira pointed out, Cuba’s extremely low HIV prevalence must be due at least in part to the quarantine. Given the country’s apparent success in handling HIV/AIDS, there must be lessons to be taken from Cuba’s public health actions.

An aspect of Cuba’s treatment of HIV/AIDS that is less controversial but probably very effective is compulsory testing. Mandatory HIV screening is also arguably a human rights violation and not an action that would be accepted in a country like the United States. However, something that may be taken away from Cuba is its aggressive screening and tracing of sexual partners for those testing HIV-positive. In a country like the U.S., there is definitely room for such aggressive prevention and treatment measures. For example, HIV tests should be standard components of physical exams, along with other blood work—granted it must be approached, at least initially, with sensitivity, given the nature of the disease. Making HIV screening a routine medical practice will surely lower rates of the disease and may eventually remove the stigma associated with requesting an HIV test in the first place.

Clearly, Cuba’s campaign against HIV/AIDS was extreme and cannot be replicated. However, other countries can learn from certain actions taken by Cuba, actions that have contributed to the country’s effective handling of the disease.

Main Reference: Hansen H & Groce N (2003). Human Immunodeficiency Virus and Quarantine in Cuba. JAMA. Retrieved from http://jama.ama-assn.org/cgi/content/full/290/21/2875.

Cuba: The Moral Ambiguity of Preemption

Obviously, on principle and in hindsight the Cuban government’s decision to quarantine those citizens who tested positive for HIV was terribly unfortunate and undoubtedly caused enormous hardship. However, I feel as if it is not cut-and-dry enough to easily determine whether or not it was a flagrant violation of human rights.

For one, according to that report it did occur at a time when very little was known about HIV except that it was a deadly virus. Therefore the government’s reaction was not completely inappropriate. On the other hand, it could certainly be argued that it is simply unconscionable to preemptively isolate a group of people, stripping them of their rights, without sufficient evidence to support such a drastic measure. Where then does a government or a society draw the line? At what point do you decide that an individual’s rights should be ignored in order to protect the society as a whole?

Of course this decision is made easier when you are fully aware of the communicability of the disease and/or the consequences of your action or inaction. I feel it would be completely justified to quarantine a small group of people if the disease they carried had the potential to wipe out thousands or hundreds of thousands of others if unleashed upon the population. However, the problem is with this policy of preemption.

We have seen this ethical and moral ambiguity in other areas of society as well. Was it right to have attacked Iraq for possessing weapons of mass destruction without solid evidence that they had them? Was it right to intern the Japanese during World War II on the chance that they would leak government secrets? So was it right for the Cuban government to quarantine HIV infected citizens without knowing if they were seriously contagious? In retrospect these three are certainly examples of horrible violations of human rights, but what if things had turned out differently? What if Iraq did have WMDs that it intended to use? How many would change their view if it had turned out that HIV was wildly contagious and could be spread through the air? I think then the decision to quarantine would have been completely justified and perhaps even lauded for possibly saving countless lives.

Cuba, Cuba!!

Quite frankly, it was a dehumanizing, awful move. I most definitely don’t agree with removing people from a population based on their health status.  It just isn’t fair for us to play God and decide other peoples’ futures based on our own selfishness.  It seems as though health professionals and powers in government tend to feel they are entitled to make these sorts of decisions.  I strongly disagree, especially in a nation where we are so incredibly adamant about keeping our rights and freedoms.  

I can’t help but think, however, that the consequences of removing HIV-positive Cuban citizens from the population have been incredible.  The percentage of the prevalent population of HIV-positive people in Cuba was reported extremely low in 2003, and perhaps these statistics have been hugely influenced by the expulsion of these people from society.  I guess overall, I am against this sort of movement.  However isolation may be the trick to at least temporarily controlling certain things until further action can be taken. 

India: A Split Healthcare System

India has seen increases in life expectancy and the government has devoted significant sums of public and private money to recent health projects. However, these health projects often only benefit specific groups that are already more well-off than the rest of the population. Most importantly, the government has now decided to invest in the private sector, while the public sector continues to deteriorate.

So why is there this dramatic split within the health care sector? Whereas Singapore, Japan and more recently China have emerged from rural societies into modern economies through industrialization, urbanization then modernization, India seems to have skipped a step. There has been a quick and dramatic split in society with the minority changing from rural to modern and the majority remaining in poverty.

The divide between public and private enterprise is easily experienced by the fact that cell phone service is more reliable than electricity. Another example is the fact that many foreigners come from abroad for surgery in major private centers, while rural public centers continue to deteriorate. With such a badly split healthcare system, how will India’s government respond when care is being rationed by profit in the private sector and wait times in the public sector?

I believe that major change in the political agenda or more public-private partnerships will be the only salvation for India's health care system. As a major change in political priorities is unlikely in the near future, focus should be put on building public-private partnerships.

India and its private health sector perpetuates health inequalities

An article by Yip and Mahal in Health Affairs titled "The Health Care Systems Of China And India: Performance And Future Challenges" discussed a couple issues of India's health care system. First, India's economy is definitely growing and will continue growing for many years to come, primarily due to the emergence of international countries such as the US and others that rely on outsourcing work to India. As a result of this, an influx of money flows into the country, theoretically trickling down from the government to the public. Unfortunately, however, there are greater strides in the private system than the public one. Thus, even though the economy is growing and more people have moved to the middle class, a segment of the population that is considered indigent still have problems accessing basic health care services. The paper also highlights that the unregulated private sector continually lures practicing physicians into private practices catering to the more affluent populations, creating an income gap that results in a disparity in health outcomes favoring the wealthy. Additionally, the rise of medical tourism in countries such as India, shifts the emphasis on building the private sector, leaving the needs of India's impoverished unmet.

It's great to hear that the Indian government wants to invest 1-2% of the nation's GDP into health care, but before we all jump up and claim victory, we must follow where the money goes, because according to Yip and Mahal, the money will likely be used to build up the private sector. And wherever the money goes, quality and access usually follow. It is a true shame, as Sonny said in his blog, that many of the people waiting for care might never actually get the health care they need...

"Will we in the West realize our potential or will we sleep in the comfort of our affluence with apathy and indifference murmuring softly in our ears?" Bono, "The End of Poverty"

The balance between protecting individual rights and the health of the public

While Cuba's approach to HIV/AIDS containment was definitely a violation on human rights, they have managed to maintain the lowest prevalence of HIV in the Americas. I think we can be somewhat forgiving of their approach because at the time, the etiology of the disease was not fully understood. From what I've read up on this, the first case was not detected from a gay male, but from a heterosexual volunteer returning from Africa, therefore, there was very little stigma attached to the disease initially (http://www.medicc.org/ns/assets/documents/Cuban%20HIV%20Strategy.pdf). It was understood to be a sexually transmitted disease that could infect the population regardless of sexual practices. Therefore, the HIV approach taken by Cuba was made based on epidemiological evidence, and did not involve them targeting certain populations and isolating them. While debate arrived when Cuban health officials implemented a sanatorium policy for people diagnosed with HIV or AIDS,they defended their actions by arguing that they were able to provide patients with the most effective mechanism for providing comprehensive biological, psychological,and social care patients required.

I don't believe quarantining HIV patients is morally the right approach to address the HIV epidemic, but it did prove effective. Public health professionals are faced with the arduous task of balancing and protecting the rights of individuals with the health of the public. Which raises the million dollar question, at what cost do we compromise individual rights in order to protect the public? This reminds me the case of Andrew Speaker and the CDC in May 2007. Speaker was infected with a drug-resistant form of TB and decided to travel to Europe, exposing many people to the disease. The CDC made the decision to order him back and quarantined him. Unfortunately for the CDC, Speaker was a lawyer and was able to highlight his victimization and win over the American public. In my opinion, certain cases do call for the government to take action and compromise individual rights for the greater good.