International Association of Physicians in AIDS Care, Journal: January 1998 - Volume 4, Number 1
Jim Graham

The Cuban people are suffering.

That was clear to me during a recent visit to Havana, under a US license, to participate in an HIV/AIDS meeting. The suffering should be good news for Senators Jesse Helms and Robert Torricelli, the principal authors of the current harsh policy aimed at our island neighbor. In a "hit 'em hard, when they're down" move, Torricelli's "Democracy in Cuba Act" in 1992, followed by even tougher restrictions in the Helms-Burton Act in 1996, invigorated the longest embargo in modern history, all timed to take advantage of a Castro regime already severely weakened by the loss in the late 1980s of its Soviet-bloc trading partners. A blockade is meant to hurt. It is "an effective tool in leveraging governments to accept international standards of conduct," as Torricelli put it.

But this embargo runs afoul of international human rights agreements by restricting the purchase by Cuba of humanitarian goods, including food and medicines, from US companies or their foreign-owned subsidiaries. The terms are virtually unprecedented. US embargos against China, North Korea, Vietnam, Cambodia, Uganda, Iran and Nicaragua each permitted access to basic humanitarian goods.

The State Department would have us believe that the Democracy in Cuba Act regulates, rather than prohibits, such purchases. But in fact very few commercial license applications submitted after 1992 have been approved. (One request for $193 for x-ray replacement parts was denied in 1995 as contributing to "medical terrorism.")

The results are devastating--and nowhere is that more clear than in the area of AIDS, where American pharmaceuticals have a preeminent role worldwide. The review by American Association for World Health concluded, "Limiting the access of Cuban AIDS patients to medicines is the most damaging result of the US embargo that we observed."

With a public health system that once rivalled those of the most developed countries, and mandatory testing and quarantines that involuntarily isolated people infected with HIV to sanatorias, Cuba controlled the AIDS epidemic for years. Admittedly, it did so with harsh measures. During our meeting, several Cubans living with HIV reported on the circumstances of their "detection" as HIV-infected. One person was studying chemistry in Moscow when a telegram was received telling him to return home because his father was ill. When he arrived in Havana, he was informed of his HIV status and then committed, without hearing or recourse, to what was an indefinite term in the sanitarium.

The AIDS sanatorias are now mostly voluntary. Cuba can no longer afford such luxuries. During the "Special Period," a wonderful Orwellian phrase describing belt-tightening brought on by the collapse of the Soviet Union, the Cuban budget for public health fell from $227 million in 1989 to a low of $66.9 million in 1993. Virtually overnight, $80 million in Soviet medical support was lost.

Not only is there less money, but due to the embargo, medicines cost more. The AIDS response suffered with other medical needs. Prevention strategies--including elaborate Cuban detection efforts--withered. Condoms were scarce.

At the same time a cash-starved economy, with the blessing of Fidel Castro, began to lure tourists from Latin America, Europe, and Canada to newly restored or constructed luxury hotels and fine Cuban beaches. There is no old-regime-style gambling, but drug use is on the rise and there's prostitution of the sort that has not been seen in Cuba since 1959.

In a country where a prominent physician makes $40 a month, the abundance of sex workers looking for a $50 assignation is no surprise. The beauty of the Cuban people is once again among the island's chief attractions. But mixed with an economy that can afford neither quality condoms nor prevention efforts, it's a recipe for disaster.

The overall AIDS totals are low by American standards: out of a population of some 11 million, about a thousand people are living with HIV or AIDS, equally divided between homosexual and heterosexual sources of transmission, with as yet no reported IV-drug use related infections. But Cuba may in fact have lost control of the epidemic. For the past two years, there has been a soaring increase in reported new HIV infections.

The onslaught of AIDS could not come at a worse time, since the public health system, once Cuba's pride and joy, has all but collapsed. Even the most basic medical supplies--disposable syringes, surgical sutures, cotton swabs--are in dangerously short supply everywhere. People typically take their own sheets to the hospitals. Cuba has few HIV/AIDS medications, including the new combination therapies that are bringing hope to many in developed nations.

The impact of all this is known first-hand by Jorge Pérez, MD, who directs much of Cuba's AIDS medical work. In late 1993, Pérez welcomed a delegation from Merck to Havana to consider, among other things, the possibility of launching AIDS clinical trials. After a week in Cuba, the Merck representatives recommended to proceed. Cuba made sense since it had a small epidemic, good controls from the sanatoria system, and limited experience with AIDS drugs. In light of subsequent events--Merck's Crixivan is an important AIDS drug today--this could have been an important opportunity. But it was not to be.

The US Treasury Department found Merck had violated US law and fined the company. Merck paid a "settlement" of $127,500 for what the company characterized as "inadvertent and technical" violations. CEO Raymond Gilmartin declared, "Merck would never consider conducting business in Cuba or with a Cuban national unless or until the Cuban embargo is lifted."

Asked how he felt about that result, Pérez responded, "I was angry. The only thing this effects is people. The action is not against the government, but just against sick people." Pérez recalls another example involving a medical trade show in Texas. He approached a representative of the company that manufactures flocytometers (HIV-related equipment that measures the strength of the immune system). Upon seeing Pérez's card, the representative responded, "Why should I talk to you, since you are not allowed to have the equipment? It would be a waste of my time." So whatever the letter of US law, its general impact has a chilling effect on even considering trade.

Of greater concern is the embargo's killing effect. Pérez says that 10 Cubans have been given donated AIDS combination therapies, three of whom are responding well. What will happen when they run out of these medicines? Somehow Cuba managed to buy a flocytometer--Pérez won't say from whom--but what will happen when it needs repairs?

The "Cuban Humanitarian Trade Act," which would exempt humanitarian goods from the US embargo, is pending in Congress. Whatever the justification for economic sanctions against the state of Cuba, there can be no case for depriving the people of Cuba of the ability to purchase food and medicine.

980101
IA980101

Copyright © 1998 - International Association of Physicians in AIDS Care. All rights reserved. http://www.iapac.org