March 18, 2020
The photo of a large, multi-storied cruise ship docked in Havana harbor lit up my internet feed today and underlines, for me, the contrast between Cuba’s approach to a public health crisis and our own patchwork of confusion, incompetence and greed. The ship, the MS Braemar had been on the seas for a week waiting to find a place to berth and to assess and treat its 682 passengers and 381 crew members who were exposed to the novel coronavirus that is sweeping across the globe. Five passengers tested positive for the virus and 50 others, including the ship’s doctor, were being isolated and under observation.
Only Cuba offered sanctuary—a place to pause and a protocol of welcome and safety, both for those on the ship and those on the island
Why Cuba? A lot of people are wondering and asking this, but for those of us who have visited the island and who have interacted with the health system there the answer is clear. Cuba is prepared for this pandemic with a finely tuned and integrated public health system. They know what to do. But even more than that, Cuba has practiced health solidarity for decades––training doctors from all over the developing world to return to their countries and serve and sending its own doctors to offer primary and specialty care both after disasters and in an ongoing exchange. They are ready for this and their view of health care as a human right is not limited to the borders of their own small island nation––it is a global vision.
The irony of the cruise ship is not lost on me. Only a few months ago, the Trump administration tightened the already inhumane blockade and travel ban on Cuba by prohibiting cruises originating in the U.S. from stopping in Cuba. When I last visited Havana in January of this year, the harbor was empty and the streets of the old city, which in the past few years had been full of tourists spending the day (and their money) in this colonial treasure, were noticeably quiet. So ––no U.S. cruise ships to help the Cuban people survive, but the Cuban people will help the passengers of the Braemar find shelter in the storm.
During previous visits I had seen Cuba’s very effective Family Nurse-Doctor program in action in the lives of the 4 generation Cuban family I stay with. The matriarch of the family, a 93-year-old with high blood pressure and very thin skin that bruises and opens at the slightest bump, really can’t go out anymore so the doctor visits her regularly to check her skin and her blood pressure. My friend, an actress who works many jobs to support the family, uses a combination of herbal medicines she is prescribed through Cuba’s green medicine program and obtains at her local neighborhood health center to treat musculoskeletal issues; her daughter, my honorary niece, has celiac disease and was followed closely during her recent pregnancy to be sure that she stayed healthy. If she had needed it, she could have stayed in a special maternity home near her house to be sure her diet was adequate, and her pregnancy was going well. And her daughter, the littlest member of the family, is closely monitored by her pediatrician who has recommended a gluten free diet until she can be tested at two years of age to be sure she does not have celiac disease. All of this care is free. All of this care is delivered in a variety of settings located in the neighborhood. And delivered with love.
Yes, there are shortages of medications, mostly due to the U.S. blockade which includes medicine and humanitarian aid. Yes, families often have to provide meals and sometimes even clean sheets and towels and even medications sent by family in the U.S. to patients in the hospitals due to shortages. But the intention to ensure that health care is available to all is alive and well in Cuba.
Beyond the care system that is visible even to me, a foreigner, at the foundation of the Cuban health care system is a network of public health information that guides decisions about where resources are allocated. An annual assessment is carried out by each neighborhood primary care clinic and neighborhood clinic. The data about how many smokers, how many pregnant women, how many alcoholics, how many with mental health issues, how many with diabetes, hypertension, and on and on is collected, most often in paper and pencil anonymous surveys conducted through visits to homes, schools, daycares, factories and businesses. This data is passed on to the National Ministry of Health which can then determine which areas are most in need of doctors, equipment, and educational interventions. And at the community level, block associations, organizations of women, of school children, and of workers can be mobilized quickly to respond to outbreaks or disasters.
I saw this first-hand after a once in 100-year tornado twisted through Havana during my visit in January of 2019. Without being prompted or even asked, neighbors in the unaffected areas of the city began collecting supplies. They, who have so little by our standards, gave freely of their canned goods, clothing, shoes, medicines even beauty supplies to those who had lost everything. And the government quickly moved in to organize distribution––to make sure that everyone would get their share, not just those who had family or friends who were willing to donate.
The fight against dengue, a mosquito borne infection, that can be very serious in Cuba requires constant neighborhood level assessment of areas of standing water in which mosquitoes breed, knowledge of and observation of symptoms, and immediate isolation when someone is infected. This is carried out year-round to keep sickness and death from this disease at bay. It is public health integrated with clinical care and contributes to Cuba having among the best indicators of health in the world––low infant mortality and maternal death rates, and high longevity.
Waking in Havana, my recently published memoir about my experience in the early years of the AIDS epidemic––as a pediatric AIDS nurse in Newark, NJ, as the widow of someone who died of AIDS complications and as a volunteer health educator in Havana’s AIDS Sanitorium––explores this contrast between US and Cuban responses to a different pandemic in a different era. As soon as Cuban scientists and doctors learned of the existence of this new deadly disease, before the first case had been diagnosed on the island, they began preparing a national coordinated response that included widespread testing, contact tracing, and the decision to isolate people who tested positive for HIV in residential institutions, called sanitoria. This last intervention, though in keeping with public health practices for preventing the spread of infectious diseases, was very controversial in the global AIDS community.
In Waking in Havana, I tell the stories of five Cubans with HIV/AIDS who lived through those early days. Separation from their families and communities was hard, though they received state of the art care, and the program went on well past the time that was necessary for public health reasons. But it did succeed in keeping the AIDS epidemic in check in Cuba, which has among the lowest prevalence of HIV/AIDS in the world and in 2015 was recognized by the World Health Organization as the first country to completely eliminate mother to infant transmission of the virus.
In 1988, in my small clinic in Newark, NJ, my team cared for 75 infected children, many of whom had already been orphaned by AIDS and were living with grandmothers or in foster homes. Although a national response to the epidemic had begun a couple of years earlier, it had taken U.S. President Ronald Reagan six years after the first cases appeared to utter the word “AIDS” in public. Our clinic families faced stigma every day––from landlords, schools, daycare centers, hospital staff and funeral directors. Many drove half-way across the state to pick up their child’s medication to avoid being seen in their local pharmacies. And although special programs were set up to pay for these expensive life-saving medicines, families had to make their way through a maze of bureaucratic obstacles to obtain adequate health care for their children.
HIV/AIDS and Coronavirus could not be more different in how they are transmitted, how contagious each is, and the breadth and depth of their effect on the world. But the fear and stigma that an AIDS diagnosis engendered in the 80’s and 90’s (and unfortunately, often still does) has attached itself to this new viral outbreak. Every time Trump talks about the “Chinese virus” I remember the days when AIDS was referred to as a disease of the 3 H’s—homosexuals, Haitians and heroin addicts. Hundreds of thousands of people around the globe will surely die, perhaps millions, before this pandemic wave ebbs. This was predicted by Bill Gates and others concerned with global health years ago, yet the US did nothing to prepare. On the contrary––states, including New York, closed hospitals, let a nursing shortage go mostly unaddressed, and, now we find out, are not prepared with enough personal protective gear to get through two weeks, let alone the months we may face.
As I spend most of my time in the cocoon of my home these days, only going out for a breath of fresh air, some exercise and some groceries, my thoughts travel to Cuba. 4 cases have been diagnosed there, Italian tourists, but more are sure to come. Already, my friends tell me, the testing and screening of the population in primary care settings has begun. Already TV, radio and educational flyers are informing people about this new threat to their health. Already factories that make school uniforms are being retooled to make masks and gowns. Yes, Cuba has shortages of almost everything these days––but there is no shortage of preparation––or solidarity.
4/7/20
Update: I wrote this initial post almost a month ago. Oh how the world has changed. New York City, where I live, has become the epicenter of the pandemic. We are shopping online now and being careful with the food we have to make it last (something I became very familiar with during my time in Cuba). A neighbor across the street is in ICU and several friends and relatives are at home with mild cases. We are advised to wear masks when we must go out and my daily walks have become a few times a week.
My friends in Cuba tell me they are also under orders to stay at home and to wear masks when they go out. Enforcement, which has been really lacking here in Brooklyn, includes not being able to get on a bus without a mask. One friend was sent home to get his mask by a public health worker on the street. Cuba now has 392 cases and 11 deaths. Millions have been screened in primary care and thousands are isolated and under observation. The mostly British passengers of the MS Braemar were sent to their home countries by charter flight.
And Cuba has now sent hundreds of doctors to overwhelmed Italy. Brazil, whose right-wing President kicked out Cuba doctors at the bidding of Trump, is now begging them to come back. And they will.