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.

Cuba--Mixed results

Basically I kind of agree with Yahaira's comments. It is unthinkable to have the HIV infected confined today. But back in 1980's, little was known about this virus disease...sort of a mystery killer. Any disease new and unknown to human mind triggers fears and Cuban government reacted "overboard." This is a negative reaction but the end results did generate some positive outcome. Overall, it is a mixed baggage. The blog question stated "Cuba compulsorily tested thousands of its citizens for HIV..." ===> Just exactly how did they pick up those thousands of people? Which population did they single out? Young and gay or what? Would the people who were tested being viewed as "diseased" even though they were tested negative? Were those tested negative returned to their hometowns rejected ?

We may never get precise assessment on these issues, but clearly it violated many people's rights. Do some of the consequential positive outcomes justify this act? Hard to say, I don't know.

In addition, in Michael Moore's film which we viewed at one of previous classes, Cuba was glorified as a generous and friendly country. It was all positive and little was said about any negativity. Any comment from any single source might be biased. I wonder is there political propaganda involved in this film since Cuba is trying hard to promote its image to the west. The universal coverage is definitely welcomed by majority of Cubans though they have many complaints toward many social policies under this oppressive regime. The health care delivery seems to be the bright spot in this island nation plaqued with several social and economic issues.
One Cuban woman asked "If a small country lacking natural resources can and willing to commit to the univeral care, then why would a wealthy and big country like the States won't do it?" This might be worthy for our politicans to think about it.

Cuba---AAHHHH!

So this is wrong wrong wrong! granted i will not hold it against the government because of the lack of knowledge and understanding of the virus. But it would never be okay for this to happen present day.  

Aside from this, however, Cuba has done an excellent job of HIV screening and prevention.  Perhaps stemming from something they learned in the 80's.  Here is what i found about the quarantine santorium.  

"The HIV quarantine facilitated the education of patients and their families about HIV, allowed for directly observed patient treatments and safeguarded the general population of Cuba. Meticulous identification of every HIV positive individual in Cuba allowed the tracking back to the “source” of the patient’s HIV infection, whether from overseas or in Cuba. Cuba has an extensive confidential database of HIV positive individuals along with all their intimate contacts who have contracted HIV or remained HIV negative."

Now while I completely agree with Ara and his explanations of how this is wrong, I also think perhaps it did some good in education.  While this was going on, the HIV/AIDS stigma in the general population was also attacked. 

"Cuba stopped quarantining in 1993 and allows people with HIV to stay at home after a course to teach them how to look after themselves and not spread the virus.Universal free access to locally made generic antiretroviral drugs has kept AIDS cases and deaths very low, said the UNAIDS program. Almost 20 years later, Cuba has one of the lowest rates of HIV infection in the world, a prevalence of less than 0.1 percent of its sexually active population."

So obviously something went right, and Cuba has HIV/AIDS under control. Something that is hard to say about various Latin American countries. 

CUBA: CIVIL CONFINEMENT

Ahhhh yes, public health law example at its finest once more. It's good to be back! This particular case has international concern written all over it. I'll describe what the challenges are and how this case would be interpreted here in the US. I suppose the clearest way would be in outline form. Bare with me :)

I. Challenge:

A. The benefits of public health information systems, collection of data, etc.: you can detect hazards and health risks and gain information to inform the public, intervene (and evaluate existing interventions), and influence policymakers. The trade-off: individual autonomy, privacy…..public health success is due to the relationship with society: public health authorities safeguard public interests/rights, so as to be trusted. This will then make people feel comfortable enough to cooperate with public health measures and regulations.

B. With compulsory testing and screening, we run the risks of defining a class (generic/specific: which brings forth over/under-inclusive issues).

II. Mandatory Reporting of diseases and other health conditions (in the US):

A. States differ as to: what is reported, who reports, to whom the report goes, when the report is necessary.

B. HIV case reporting:

a. Public health professionals have a responsibility to protect the population and justify reporting by the ethics of collective responsibility. Doctors however have a priority to safeguard patient interests and their doctor-pt relationship.

b. To breach that confidentiality by reporting names and sensitive personal data, patients believe there will be room for discrimination, invasion of privacy, and political retributions

c. The benefit of HIV reporting: better monitoring, better allocation of resources and services, and, clinical benefit for the patient.

C. Partner Notification

a. Three distinct meanings:

1. Contact tracing: whereby the public health agencies need to identify, locate and inform the sexual partners that are at risk of infection.

2. Duty to warn: the doctor’s duty or power to inform their patients’ sexual partners

3. Right to know: common law duty of infected persons to disclose their sero- status to their partners.

D. Fourth Ammendment: gives right of individuals to be “Secure in their persons” and not subjected to “unreasonable search and seizures”

a. It is seen by the Supreme Court that collecting and analyzing biological samples is a “search”. So, the Question is, is it unreasonable?

b. Court has stated, “special needs beyond the normal need for law enforcement” will

not require warrants/probable-or-reasonable causes for the search.

III. Confinement (US constitutional standards)

A. Three types of Confinement (international application):

a. Isolation: separation for the period of communicability, of known infected persons in such places and under such condition as to prevent or limit the transmission of the infectious agent

b. Quarantine: restriction of the activities of healthy persons who have been exposed to a communicable disease, during its period of communicability, to prevent disease transmission during incubation IF the infection SHOULD occur.

c. Civil commitment: detention for the purpose of care and treatment.

B. Pre-civil Rights Era: Constitutionality of Civil Confinements

a. Essentially, it was believed that there is no liberty to harm others. However, confinements of “public necessity” and or reasonable means can be done.

b. Three general limitations:

i. Subject must actually have the infection in order to be confined: however, “Suspect conduct and association” is justifiable à social prejudice, discriminatory, stigmatization, unequal

ii. Safe & Health Environment during Confinement: people have 14^th amendment liberty interests toward “freedom from bodily restraint”, “reasonable safety and care”, and provision of food, shelter, treatment, etc.

iii. Not exercised w/ racism or discrimination against a class or vulnerable group

C. Post-Civil Rights Era: Constitutionality of Civil Confinements

a. Since people are being confined for indefinite periods and for their likely “future risks/dangerousness”, the deprivation of liberties is violating a fundamental right which requires strict scrutiny.

i. Person must pose a significant risk, compelling state interest needed

ii. Well-targeted intervention is needed: not over-or-under inclusive

iii. Least restricted means

iv. Procedural due process is necessary: counsel, hearing, appeal.

a. For compulsory treatment of competent adults: must show high risk and appropriate treatment

IV. Solution?

A. In Lawrence Gostin’s book, “Public health law: Power, Duty, Restraint”, he proposes an idea in which there is maximization of privacy and maximization of use of sensitive data by public health officials when deemed necessary to the social good. First you acquire the identifiable data based off of a legitimate public health purpose. Second, you will store and use the data within the confines of the public health system. And, third, you can disclose the info w/o consent only when: to other public health professionals/doctors. Essentially, are you justified in acquiring the identifiable data? If so, are you taking the necessary privacy and security measures?

B. As we bring all these viewpoints together, it can be said that Cuba’s treatment was
undoubtedly a violation of human rights. Civil confinement should be seen only as a
last resort if it is deemed a necessity toward social interests. Furthermore, to
confine, test/screen, and marginalize subgroups of population—as “unconstitutional”
it is in an international sense of the word—the withholding (or lack thereof) of
treatment to the communicable disease in question further hinders the justification
of violating their privacy, liberties, and autonomy.

A Lost of Social Medical Care Compass in India?

When a Disney TV movie has India in the movie, it makes you wonder about what were the executives thinking about sending their stars to a country with such a broken system as seen in the Time's Photo Essay. Then, money comes to light. Disney got plenty of money to filter any member into India's "priority" system: those with either money or power to their name/family name goes first and gets best treatment. Its very unlikely that those with that, would get star treatment which I think every global citizen deserve.

A lost of social medical care compass in India is the best way I can express what I mean and how I feel about the money takeover. India is a country rich in culture, family traditions, and I like to think that India has made long strides in social rights movements after Gandhi. My time spent early this year may not echo that, especially those who lived in the village in the background of my photo (Me outside village near Mathura, India). Very few GIs nearby and many villagers do not know what a specialist even is. Most rely on the elders or drug stores to help diagnose and treat symptoms they have or feel. Foreigners visiting India's towns help create a demand for GIs to be nearby the villages, which in turn will create a growth in the village but also help the local population with their health care. What happen to desire to help from within India, rather than outsiders helping externally?

One caption from the essay, "The government has promised to increase public health spending from 1% of GDP to up to 3% by 2010. Until then, many Indians will just have to wait." Wait for what? Indians are not fortunate to have a Canadian system where they can wait and know that they will eventually be covered. Here, Indians are waiting hoping and praying that one day their problems will disappear. Its a shame and a sad thing that the one day which most Indians wait for will never come first than the day that they pass away. Hopefully their future generations will be lucky enough to have that changed.

Song of Blog: to keep the Indian theme, this song is from the Hindi film Gangster: Tu Hi MeriShab Hai.

Blog Questions:

Blog Questions:

Cuba

'According to the UNAIDS report of 2003 there were an estimated 3,300 Cubans living with
HIV/AIDS (approx 0.05% of the population). In the mid-1980s, when little was known about
the virus, Cuba compulsorily tested thousands of its citizens for HIV. Those who tested
positive were taken to Los Cocos and were not allowed to leave. The policy drew criticism
from the United Nations and was discontinued in the 1990s.

How do you feel about this? While this is an obvious violation of human rights, do you
see any derived benefit of this action such that it is a worthwhile tradeoff?






India

India’s economic is rapidly growing and has significant impact on its population. In 1985, 93% of the population had an annual household income less than $5.40 per day. In 2005, this number has dropped to 54%. India is emerging out of poverty and many are joining middleclass population. Looking at the picture essay on Time magazine, do you think India is ready to tackle the health and development challenges as it transitions to a developed nation?


http://www.time.com/time/photogallery/0,29307,1711814_1523732,00.html