Dialectical Anthropology 28: 289–305, 2004.
2004 Kluwer Academic Publishers. Printed in the Netherlands.

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The Cuban Response to the AIDS Crisis: Human Rights Violation or Just Plain Effective? GOWRI PARAMESWARAN State University of New York, New Paltz, 75E Manheim Boulevard, New Paltz NY 12561, USA (E-mail: [email protected])

With a population of 11 million, Cuba is the largest island among the Caribbean nations. It has suffered half a century of US trade embargo after the communist revolution that brought Fidel Castro to power. Until the end of the cold war, it had been receiving significant financial support from the Soviet Union. After the break up of the Soviet Empire, funding for Cuba dried up. In the 1990s Cuba has seen a 50% decrease in its GDP, though its economy has recovered considerably since 2001. Since the onset of the AIDS pandemic across the globe, Cuba has undertaken some controversial steps to tackle the crisis with very limited resources. The Cuban health ministry has had spectacular success in limiting the spread of AIDS among its population.1 In spite of its success in stemming the spread of the AIDS epidemic, the Cuban government has been maligned by some countries and human rights organizations. Others, especially aid organizations in the third world have proposed Cuba as a model for other developing countries grappling with the AIDS epidemic.2 Cuba has one of the lowest AIDS infection rates (less than .03) in the world. This is astounding when compared to the other nations of the Caribbean islands, which have had on an average, AIDS infection rates of 6–8%. To give the reader an idea of the magnitude of the achievement by the Cuban government it is important to point out that Cuba has an HIV infection rate that is 30 times less than the infection rate in the USA, which spends a lot more on AIDS prevention activities. As of November 2002, 3775 cases of HIV/AIDS had been reported in Cuba, 1460 of whom had already developed full-blown AIDS, and 998 of whom had died, including 57 who died of causes unrelated to the disease. The death rate due to HIV/AIDS complications has been a lot less than Cuban officials expected and certainly much less than its neighbors. According to Public Health Ministry statistics, in the mid-1990s the state spent around 14,000 dollars a year per asymptomatic

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HIV-carrier and 24,000 dollars for each patient with full-blown AIDS. AIDS treatment is universally available to all Cubans.3

Non-governmental organizations (NGOs) in Cuba The remarkable statistics cited above couldn’t be attributed to the work of international non-governmental organizations. Before 1990, there were no NGOs in Cuba. The government provided most of the social services like health, education, and employment. However, with the economic crisis in the 1990s, NGOs like Oxfam first made their entry into Cuba. In many developing countries, NGOs have been instruments of imposing the neo-liberal regime of the first world on to the third world.4 However, Cuba has always emphasized collective action amongst its people and the government has played a very constructive role in encouraging the effectiveness of the NGOs.5 Thus, the entry of charitable organizations into Cuba has been highly dynamic because of the political awareness of the population and the participatory nature of the Cuban society. Non-governmental organizations in Cuba have been mediums to put into practice the basic tenets of the Cuban revolution. There have been several advantages to having NGOs working in partnerships with the Cuban government; for example, there has been an emphasis on creative solutions to new problems, the ability to take risks on small projects and the local residents taking on ownership for local changes.6 NGOs in Cuba have mainly played the role of conducting exploratory work and acting as liaisons to the donor nations in the late 1990s.

History of AIDS in Cuba Since its very inception after the Cuban revolution of 1954, health was declared as one of the major priorities of the new communist state. The health care system was and is still based on the principles of equality and social justice. Health was the responsibility of the state and the right of the people, care was thought to be comprehensive, integrating curative and preventive services, and health-care was to be free and accessible to all.7 To understand the success achieved by Cuba it is important to review the history of the onset of AIDS in Cuba and the governmental response to the onset. Two years before HIV/AIDS was officially recognized as a

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disease by the United States government and declared a threat to humanity, the first national committee for the prevention of the spread of the AIDS virus was already constituted in Havana. The members of the committee were from the highest echelons of the Health ministry of the Cuban government.8 The priority that the Cuban government has placed on health is indicated by the fact that Cuba has consistently spent more than 7% of its GDP on health, higher than all other developing countries with similar incomes. Over the years it has also pursued advancements in biotechnology applications as the new frontier of medicine. In fact it has the only known vaccine for the Meningitis-B virus.9 Cuba has also prioritized prevention activities over curative endeavors as being both cost-effective and involving less human cost in stemming epidemics. Today, Cuba is experimenting with vaccines for AIDS, malaria and a number of other infectious diseases.10 In 1980, word got out that there was a strange new illness being observed in parts of Africa that might have been around for many decades. Cuba at that time had a number of soldiers working as peacekeepers in many parts of Africa. There were professional Cubans sent to many developing countries around the world helping in the rebuilding of nations. It was recognized that AIDS would arrive in Cuba sooner rather than later. The Cuban government swung into full gear appointing a commission to investigate the disease and recommend appropriate measures to tackle it. The National AIDS Control Organization was established in 1981. Dr. Jorge Perez, a Canadian trained epidemiologist was given the leadership of the commission. He had been the director of the Pedro Kouri Institute of Tropical Medicine prior to being put in charge of AIDS control. In the early days of the AIDS crisis, health experts and the World Health Organization were unsure as to the transmission mechanism of the disease. Many were of the view that actual contact was needed to transmit the virus. However, Dr. Perez took seriously the marginal view that it was the exchange of bodily fluids that lead to the spread of the virus. He insisted that all external blood held in blood banks all over Cuba be destroyed. This set up a hue and cry from international health experts who thought that Cuba would have a serious shortage of blood as a result and a catastrophe would result from the blood destruction. A shortage of blood did result from the destruction for a few years. However, Cubans have historically donated blood in large numbers and they were able to make up for the lost blood. In fact, Cuba has more proportion of its population donating

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blood than any other country. The larger impact of Dr. Perez’s decision was that Cuba was the only country in the world that could prevent the spread of HIV/AIDS through blood transfusion. Thus hemophiliacs and people who need blood, who often form the frontlines in the fight against AIDS were spared.11 It is evident that the various systems for detecting the presence of HIV/AIDS was already in place when the first Cuban soldier who returned from a peacekeeping mission in Angola, tested positive for HIV. Contrary to the opinions of the US health-experts at that time that AIDS was a homosexual disease, the first case detected positive in Cuba was that of a heterosexual person. The soldier was transferred to a hospital in Havana and the pre-established ‘contact tracing’ procedure was followed.12 Cuba had for many decades sent professionals, soldiers, doctors, and teachers to economically under-developed regions around the world to help in the advancement of these nations. Thus, it was only a matter of time before other Cubans began to arrive on to the island, exhibiting the symptoms of HIV/AIDS. The HIV positive arrivals were housed in a government hospital in Havana under very restrictive circumstances. With no treatment available at that time the government exhibited extreme paranoia and prejudice against these early victims of AIDS. The movement of patients was highly restricted and they were not allowed to go back to their families. The hospital itself was a gray, forbidding place and resembled a prison more than it did a hospital. The patients report repeatedly attempting to run away and being brought back by scouts who went out looking for them. Many of them could not quite see why they had to be locked in, as they felt perfectly healthy and capable of taking care of themselves.13 The Cuban government clearly was of the opinion that societal good took precedence over the individuals individual rights.

The sanatorium system With continued insistence by the families of those initial patients and with more people testing positive for HIV, the National AIDS Control Organization had to think of a better way to quarantine the patients. Eventually in the mid-1980s, sero-positive individuals were transferred to a sanatorium called los Coccos in Santiago de las Vegas which was a bucolic suburb of Havana, the capital of Cuba. The sanatorium was equipped with excellent medical facilities to deal with the opportunistic

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infections that started cropping up among patients as the HIV incubation period (which is about 8–10 years) advanced. The diet of the residents at the sanatorium consisted of high protein meals and nutritious vegetables and fruits that were not as easily accessible to people on the streets.14 Acosta described the los Coccos sanatorium as a bright cheerful group of buildings with individual apartments. Initially, the los Coccos residents were not allowed to have sex with their partners and spouses. When a partner or spouse tested positive, they were housed in another area of the compound. Family members on the outside could visit the patients on specified days but the visits were always supervised. Later, towards the end of the 1980s, residents at the sanatorium were allowed to visit their families; however, a staff supervisor always accompanied them on the visits.15 As the number of residents in the sanatoriums gradually increased, families began to complain about the long distances that they had to travel to get to los Coccos as this was the only sanatorium for HIV-positive individuals in all of Cuba. Even though there were visiting lodges that were built right by the sanatoriums, the travel disrupted people’s daily lives and families could not visit their loved ones as much as they might have wanted to. Some families started setting up their residence close to los Coccos much to chagrin of officials in Havana. The officials in charge of the National AIDS Control Organization decided that it was time to invest resources in local communities in terms of taking care of sero-positive individuals. Thus began the immense project of building regional sanatoriums that catered to the needs of the local residents.16 The task of building local HIV care facilities might have proved too mighty a task for most other countries with the limited means that Cuba had. However, the Cuban health infrastructure had always been structured as bottom–up, with local physicians and clinics forming the backbone of the health system. By the early 1990s there were 14 regional sanatoriums, all of them fully equipped to deal with new influxes of patients. Each sanatorium had physicians trained in various areas of specialization, counseling clinics for both the patients and their families, nutritional clinics and gymnasiums.17 The Cuban sanatorium system was unique in a number of ways. Apart from a highly nutritious diet, residents were given a salary, equivalent to the amount that they had earned when they were working outside in their various professions. For many residents, even though the monthly salary was welcomed, work had given their lives meaning

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and the will to live on. Without the opportunity to work many residents felt unwanted and deprived of any motivation to live. A number of residents pushed for changes in the work policy instituted in the sanatorium system. Gradually the work within the sanatorium was assigned to the residents for extra income. Most residents began to find needs within the sanatorium that they could fulfil.18 In 1991, the los Coccos residents formed the GPSIDA, which became involved in prevention activities. Many of them began lobbying authorities against the quarantine regime in Cuba. They claimed that the artificial barrier set up between HIV positive individuals and the world was not conducive to society developing a constructive attitude towards preventing the AIDS epidemic. It fostered stigma against people living with AIDS and gave people a false sense of safety.19 In 1993, with international pressure mounting against its AIDS-related permanent quarantine policy, the National AIDS Control Organization reversed its decade long decision to forcibly detain victims of HIV and AIDS.20 In the meantime, the AIDS drug AZT was demonstrating promising results. People with HIV were beginning to live longer and healthier lives in the more developed countries.21 In 1993, quarantined individuals in Cuban sanatoriums were for the first time given the opportunity to leave voluntarily. There were several criteria that infected individuals had to fulfil for them to be allowed to stay within the local community. They had to agree to reveal names of their sexual partners as the Cuban government still follows a very aggressive ‘contact tracing’ procedure. In return, the government would keep the names of these individuals confidential. They had to also agree to live responsibly without spreading the HIV virus in their community.22 In spite of being given the opportunity to leave the sanatorium, about 70% of the residents chose not to leave.23 Some of them left for a short time but came back to live in the sanatorium. Many of them had found that life within was quite comfortable especially as the freedom that they enjoyed increased. They were allowed to leave when they wanted to and visit with their families and friends. Some worked outside while others held useful jobs inside the sanatorium for which they were paid over and above the basic salary that they received from the government. The diet inside consisted of high protein meals and they were offered the best treatment regimen available in Cuba. In the 1990s, Cuba was going through a severe economic recession and incomes had dropped by about 50% for most Cubans. Sero-positive individuals living outside did have free access to medicines but they were not offered

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the salaries nor were they given the enriched diets that residents consumed. Life inside had never seemed better!24 Reynaldo Morales, who was the first patient at los Coccos died after having lived in the sanatorium for the last 20 years. He and his wife Maria who also tested positive for HIV decided to stay at los Coccos when they were given the opportunity to move out into the community. Their son lived in a residential school and visited them once a week. Morales worked as a carpenter and electrician helping inmates by fixing up their apartments when it was needed. He was highly respected within the community and hence did not feel he could survive as well outside. He helped start an organization that dedicated itself to helping spread the message about the devastating effect of AIDS and how citizens could protect themselves. The group conducted workshops in schools and in the community, preaching responsible sexual behavior and encouraging Cubans to test themselves for HIV/AIDS. He received a number of awards and personal recognition from the Cuban government.25 In spite of the disassembling of the quarantine system, the sanatoriums are still active and the majority of sero-positive Cubans reflect favorable views towards its existence.

The substitution of the orientation program for compulsory quarantine When a local clinic finds that a person is sero-positive for HIV, the agency for disease control swings into action trying to get in touch with others who may have had intimate contact with the HIV-positive individual. The Cuban government considers societal welfare of utmost importance even if it means that individual freedom of action is curtailed. This has always been the bone of contention about Cuba’s AIDS policies with countries like the USA which proclaim Cuba to be in violation of Human Rights standards set up by the United Nations. The Cuban government has specified that it is mandatory for all HIV positive individuals to undergo an 8-week orientation course where they are taught the importance of taking care of themselves by eating well and taking their medications regularly. One of the main purposes that the orientation program was instituted was that the government wanted to convince the nervous public that most sero-positive individuals were responsible once they were educated about the disease.26 The majority of sero-positive individuals attend the orientation programs after their work-day is over, so people in their community do not get suspicious. The health ministry keeps the

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records confidential. If people did want to stay in the sanatoriums for the 8 weeks, the health ministry writes a letter to the employers of the individuals; employers are required to keep the jobs available when the patient gets back from the orientation. While they are undergoing the AIDS orientation program, sero-positive individuals receive the full salary that they might otherwise receive. More recently, the Cuban government has established orientation sites at the local level so as to maintain the confidentiality of the clients as well as to help clients keep working as they go through the orientation program. As part of the program, HIV positive patients had to establish contact with highly trained family physicians and their local clinics which would maintain health records on the patient.27 In recent surveys, most HIV-positive individuals and health care workers testify to the effectiveness of the program. One of the big benefits of the orientation program is the awareness that people exhibit towards the possibility of drug resistance that the virus may develop and the importance of taking the prescribed medications regularly. In many developing countries, where medicines are unavailable on a regular basis, patients do not follow through on their treatment and this encourages the growth of drug resistant virus.

AIDS prevention in Cuba As Dr. Byron Barksdale from the Cuba AIDS project explains, much of the other aspects of the Cuban AIDS policy are still active and these have shown tremendous effectiveness in reducing the spread of AIDS. The health ministry has enforced compulsory testing of all blood samples in the country as a result of which one of the principal modes of transmission of HIV/AIDS was removed. Even today, all blood goes through rigorous screening in Cuba.28 The health department began mandatory testing of all pregnant women for HIV/AIDS since the early 1980s. This was easy to do as Cuba has one of the highest proportions of women among developing nations, who seek pre-natal and neonatal care.29 In the 1990s, the Cuban health ministry, in a controversial move, began advising pregnant women who were HIV positive to terminate their pregnancy. Abortion has been legal in Cuba since the 1960s. The women are under no pressure to follow the advisory, though in the past, most HIV positive pregnant women had abortions. Today there are more women choosing to keep their babies till full-term. However, when the choice was not to

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terminate the pregnancy, it was mandatory for the women who tested HIV positive to undergo a Caesarian birth as this reduced the chance that the infants would be infected by the HIV virus.30 In many parts of Africa and Asia, a significant number of HIV/AIDS among children is acquired during the birth process.31 This has almost been completely eliminated in Cuba. Today, it has been found that intake of anti-retroviral medicines right after birth reduces the possibility of the child developing the symptoms of HIV/AIDS. This treatment is universally available to all pregnant women in Cuba.32 There has been a tremendous push for the Cuban population to undergo HIV testing since the disease was discovered in the 1980s. Nearly 1 million of the 13 million people in Cuba have been tested for HIV. It has the largest proportion of population in any nation in the world to have been tested for HIV/AIDS. Once a person has been found to be HIV positive, an aggressive contact tracing procedure is conducted. The healthcare system in Cuba has always been the envy of the developing world. Its citizens live longer than people in several developed countries of the world including the United States do. They have access to excellent healthcare wherever they live in Cuba. The organization of the health networks is from the bottom to the top. Thus almost all needs of a community are met by local well-organized clinics that is amply staffed and well trained. In fact, Cuba has the largest ratio of physicians to patients in the world. These clinics are given a lot of autonomy in terms of patient care and treatments used. The local clinics maintain extensive records on treatments and effectiveness, which are then fed into a computer network that integrates this data with those from other regional clinics. Thus, health professionals from all over the country, are able to learn from experiments performed and course of treatment tried in other parts of the country. Cuba has made much of this database available to international organizations and other developing countries for their own use. They recently won an international award given out by Sweden for their achievements in this area.33

Treatment issues Until the end of the 1990s, Cuba was importing most of its expensive AIDS treatment drugs from advanced countries, relying on charities to fill the medicine gap. However, with a tightening embargo and increasingly complex treatment options available, Cuba aggressively

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invested in local biotechnology firms to produce its own medicines. Cuba now produces AZT, d4T, ddI and ddC, saquinavir and nelfinavir locally because of the prohibitive cost of importing drugs from the outside. In fact, it has offered to produce these drugs at cost price for other developing countries. The US government and the major pharmaceutical companies have discouraged European countries to bring in the capital towards the end.34 In these rather uncertain times for Cuba, one group of HIV-carriers has set up a pharmacy for guaranteeing treatment for all. The group has the support of the governmental Center for Prevention of Sexually Transmitted Diseases and AIDS. They use imported medicines donated by charities like the Cuba AIDS Project. When service is interrupted for HIV patients, they can borrow these medicines and replace the used medicines when they get them back from government run pharmacies. Patients can swap unused medicines for medicines that they need as well.

A note about work with high-risk populations Besides testing, treatment and orientation, the special populations in Cuba that have formed the frontlines of the fight against AIDS are the gay community and commercial sex workers. Before the revolution in Cuba there were strong laws against homosexuals who came out of the closet that often threatened them with incarceration and steep fines. Immediately after the revolution, there was still a vestige of homophobia derived from the Stalinist perspective to social organization. Between 1965–1968 gays were incarcerated in UMAPs, which were military units where homosexuals were treated brutally with an attempt to turn them into ‘real’ men.35 There were cases where people lost their government jobs when they were thought to be homosexual. The AIDS epidemic and the period of rectification that the Cuban government went through forced administrators to actively counter homophobia in society. The 1930s ‘Public Ostentation Law’ which was used to harass homosexuals was repealed. Fidel Castro in recent years, has made several speeches against homophobia and it’s devastating impact on both homosexuals themselves and their willingness to seek treatment and on mainstream society.36 In the 1990s, the Cuban government has included freedom of alternative sexualities as an important theme in its quest for social justice. In 1995, the annual Mayday parade was lead by drag queens. Several

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official films made by the Cuban government in the last decade drew attention to details of life in Cuba for homosexuals. Gays are not organized into a political force but in many of these sanatoriums, homosexual and heterosexual couples often live together in housing complexes and socialize together. The incidence of HIV infections among homosexual and bisexual men is less than about 3000 (almost all of the HIV infections in Cuba is among the homosexual and bisexual populations). There have been massive public education campaigns conducted among the gay populations and there is easy access to condoms through pharmacies and clubs.37 Work with commercial sex workers or prostitutes has seen a number of advances and regressions since the Cuban revolution. Prior to the revolution, the island abounded with prostitutes aimed at attracting American tourists. There were also documented instances of sex trafficking.38 After the revolution, Cuban leaders took the UN guidelines on dealing with prostitutes seriously; instead of criminalizing commercial sexual activity, the government arrested and sentenced customers who visited prostitutes, pimps, and madams who were managing the trade, and people involved in encouraging the Cuban sex trade. ‘‘Legislation effective August 1997, sets fines, prison sentences of 2–5 years, or up to 8 years for public health, education, tourism, law enforcement or government officials and confiscation of property for pimps, madams and those who rent space out for prostitution.39 During the long period of relative economic prosperity in Cuba, there was little prostitution as poverty was minimal. In more recent times, with increasing levels of tourism to the country and with the economic hardship the country has been undergoing with the US trade embargo as well as the drying up of the Soviet support, commercial sexual activity is on the rise. In a recent report, observers have noted that girls as young as 13 have been noticed to haunt the major tourist spots in Cuba, trying to attract tourists and other clients. Older clients from the first world prefer young women in Cuba to service their sexual needs, as Cubans are thought to be relatively free from sexually transmitted infections. Cuba’s success in stemming the rise in AIDS infections among its population has itself become a risk factor.40

Work done on eliminating discrimination One important area that health officials had to pay attention to was the stigma and discrimination faced by sero-positive people in their local

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communities. Educational programs were launched to inform communities about HIV/AIDS and the role that stigma played in the spread of the disease. There were several laws introduced to protect sero-positive individuals from being fired from their jobs and facing discrimination in housing.41 Thus, education was aimed at protecting infected individuals as well as helping the Cuban population understand their responsibility in managing the outbreak. A second aspect of the education program was to teach the population as a whole to welcome and care for people with AIDS.42 This last step would have been impossible without the development of the patient-initiated and -run GPSIDA which was established as a non-governmental organization made up of people who were sero-positive with the charge of informing Cuban adults and children about the seriousness of the disease. Under this program, people with AIDS like Reynaldo and Maria Julia went out to spread the word that ‘‘AIDS is here, that it can be avoided, and that you need not be afraid of people with AIDS but of the virus itself.’’43

The unfinished agenda In spite of the aggressive education agenda set out by the health ministry there are several worry-some numbers put out by the World Health Organization based on a 1996 survey. The authors found that nearly 90% of Cuban women who had engaged in casual sex in the previous 12 months believed they had no chance of catching AIDS (mainly because incidence is so low). In addition, just 14.4% of female respondents had insisted on the use of a condom the last time they had casual sex, compared to 23.4% of men. As in many other countries, masculine sex roles dictate that men take risks in sexual encounters and using condoms are looked at as feminine. Thus both commercial sex workers and women in long term relationships do not insist that men wear condoms. The government’s Health Statistics Yearbook 2000 showed that 19,067 cases of gonorrhea were reported in 2001, along with 9199 cases of syphilis.44 It has been shown that the presence of other sexually transmitted diseases increases the risk of AIDS infection. As the AIDS virus mutates rapidly, there are several more recent problems that have crept in threatening to impede the progress made against the spread of AIDS in Cuba. Cuba has one of the most diverse strains of the HIV viruses in spite of the number of cases being low. This is attributed to the fact that the infections were brought into Cuba from

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various regions of Africa where Cubans worked. The task of managing and tracking the 21 different strains of the virus is made more difficult by the creeping apathy especially among youth, who several surveys report, are ignoring educational messages targeted at them.45 There are several organizations working on the uphill task of convincing Cuban women to be more assertive with the men they are sexually intimate with. The main organization include the Ministry of Public Health’s Center for Prevention of Sexually Transmitted Diseases and AIDS, in conjunction with the Federation of Cuban Women (FMC). Another is the nationwide AIDS awareness prevention campaign (APG), whose activists include 25 Los Coccos patients. With the majority of HIV patients choosing to stay on in sanatoriums once their education course is over, the APG also runs a confidential AIDS hotline for those outside.46 HIV/AIDS has been characterized as a slowly growing epidemic. The incidence rate in the Cuban population of 15–34 years of age increased from 9.5 per 100,000 inhabitants in 2000 to 12.1 in 2001.47 Much of this increase can be blamed on the economic embargo and the perception that AIDS in not a risk factor in Cuba. Combined with these is the enormous growth in the Cuban tourism industry accompanied by the rapid impoverishment of the population.48 In order to effectively respond to the AIDS epidemic, it is important to lift the embargo against Cuba. There is a severe shortage of reliable condoms as well as educational materials in Cuba, which makes informing and educating Cubans to follow safe sex practices very difficult. With soaring inflation and as women are driven to poverty they are more likely to resort to commercial sexual activity to acquire the much needed dollars. Even though that number of AIDSaffected people in Cuba is still low compared to other nations in the region, if help does not flow into the island, it would join the list of nations whose social and economic life is adversely affected by this disease.49 The Cuban case demonstrates that with a government that is committed to positive action and whose economic and political goals are intimately tied to the needs of the people, the spread of HIV/AIDS can be controlled even with limited resources. However, it is an illusion to think that the AIDS battle can be won without access to an effective vaccine.50 The international community and major aid organizations need to be ever vigilant to new needs and situations that arise within a country that will turn the course of an illness for the worse.

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Notes 1 UNAIDS. AIDS epidemic update. (2003). Retrieved on May 25, from http:// www.thebody.com/unaids/aids2003.html 2 A. Ajene, A.L. Bakhireva, D. Factor, C. Harmon, M. Kahirimbanyi, J. Sasser, and M. Thapa. ‘‘Cuba Got It Right.’’ SCP 2000 (2000); Ann-Christine D’Adesky, ‘‘Cuba Fights AIDS Its Own Way: Official AIDS policy versus routine practices.’’ (May, 2003). The Gully. From World Wide Web: http://www.thegully.com/essays/cuba/030501_cuba_AIDS_gays.html; Tom Fawthrop, ‘‘Cuba: Is It a Model in HIV-AIDS Battle?’’, Panos (2002). From World Wide Web: http://www.globalpolicy. org/socecon/develop/ aids/2003/12cuba.html; Tim Holtz, ‘‘Summary of issue of HIV-AIDS in Cuba.’’ APHA Cuba Tour (1997). From World Wide Web: . 3 World Health Organization. Treating 3 million people by 2005 (2003). From World Wide Web: http://www.who.int/3by5en/ 4 Tim Holtz, ‘‘Summary of issue of HIV-AIDS in Cuba.’’ APHA Cuba Tour (1997). From World Wide Web: http://www.cubasolidatory.net/cubahol2.html. 5 Steve Kovaleski. ‘‘Cuba Goes Green: Government-Run Vegetable Gardens Sprout in Cities Across Island.’’ Washington Post Foreign Services (1999), pg 12–14. 6 Sinclair Minor. ‘‘NGOs in Cuba: Principles of Cooperation.’’ Oxfam America. Working Paper (2000); Ed Susman. ‘‘Feature: Cuba’s AIDS policy offers lessons.’’ UPI Science News Published (2003). 7 Mirta Sixto. ‘‘An evaluation of four decades of Cuban healthcare. (2002). ASCE. From World Wide Web: http://lanic.utexas.edu/project/asce/pdfs/volume12/sixto. pdf; Ed Susman. ‘‘Feature: Cuba’s AIDS policy offers lessons.’’ UPI Science News Published (2003). 8 Tim Holtz, ‘‘Summary of issue of HIV-AIDS in Cuba.’’ APHA Cuba Tour (1997). From World Wide Web: http://www.cubasolidarity.net/cubahol2.html; The Economist. One Thing Cuba Does Right. (7 September, 1996). 9 Patricia Grogg. ‘‘Education and Prevention While Working on AIDS Vaccine.’’ Health-Cuba (March 13, 2001). From World Wide Web: http://www.oneworld.org/ips2/ mar01/18_06_066.html 10 Napoles Rolando. ‘‘CUBA: AIDS Vaccine Trials on Human Beings.’’ InterPress News Service (IPS) (January 1997). From World Wide Web: http://www.aegis.com/ news/ips/1997/IP970104.html 11 Carl Cookson. ‘‘Cuba leads way on Aids treatment and prevention.’’ The Financial Times (Feb 2003). From Database: InfoTrac OneFile (Gale); Steve Gibbs. ‘‘Threat to Cuba’s AIDS success.’’ BBC News World Edition (August 15, 2003). From World Wide Web: http://www.kolumbus.fi/medicuba.finlandia/Linkit.html. 12 Steve Gibbs. ‘‘Threat to Cuba’s AIDS success.’’ BBC News World Edition (August 15, 2003). From World Wide Web: http://www.kolumbus.fi/medicuba.finlandia/Linkit.html. 13 Keith, L. Wald. ‘‘Cuba’s AIDS patient #1 dies.’’ Hartford Digest (1995). From World Wide Web: http://www.hartford-hwp.com/archeives/43b/011.html. 14 Patricia Grogg. ‘‘Education and Prevention While Working on AIDS Vaccine.’’ Health-Cuba (March13, 2001). From World Wide Web: http://www.oneworld.org/ips2/ mar01/18_06_066.html; Tim Holtz, ‘‘Summary of issue of HIV-AIDS in Cuba.’’ APHA Cuba Tour (1997). From World Wide Web: http://www.cubasolidatory. net/cubahol2.html.; The Economist. One Thing Cuba Does Right. (7 September, 1996).

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