Ecuador holds National Immunization Day.

PIP: Ecuador conducted its National Immunization Day on August 2-13, 1999, against 10 vaccine-preventable diseases, and distributed vitamin A supplementation to children between the ages of 6 to 36 months. The goals of the campaign were: 1) indiscriminate vaccination with oral polio vaccine of all children under 5 years old; 2) nationwide introduction of measles, mumps, and rubella vaccines to all children aged 12-23 months; 3) hepatitis B vaccine introduction to all children below 1 year in the eastern part of the country, vaccination with dT of 60% of all women of childbearing age in 71 areas identified at risk for neonatal tetanus, and nationwide vaccination with dT of all pregnant women; and 4) yellow fever immunization of all children aged 1-14 years in the eastern provinces located in the Amazon Basin and of all adults aged 15-49 years in the provinces of Sucumbios, Napo, Orellana, and the area of Mumullacta in Pastanza.^ieng

Mexico introduces pentavalent vaccine.

PIP: Combination vaccines have been introduced in Mexico. The national immunization program has incorporated the measles-mumps-rubella (MMR) vaccines in 1998, and the pentavalent vaccine in 1999. The two categories of antigen composition in combination vaccines are: 1) multiple different antigenic types of a single pathogen, such as the 23 valent pneumococcal polysaccharide vaccine, and 2) antigens from different pathogens causing different diseases, such as the DPT and MMR vaccines. Pentavalent vaccines are included in the second category. The vaccine protects against diphtheria, tetanus, pertussis, hepatitis B, and other diseases produced by Haemophilus influenzae type b (Hib). Combined diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenza type b (DTP-HB/Hib) vaccine has been distributed to 87% of Mexican children under 1 year of age. Over 800,000 doses of pentavalent vaccine have been administered.^ieng

Health care systems in transition: confronting new problems in changing circumstances.

PIP: This essay introduces a series of articles in which authors from Brazil, China, the Netherlands, and New Zealand describe their health care system. The juxtaposition of these four case studies reveals how different systems confront common problems. The four systems use widely differing combinations of the same financing tactics, and all are engaged in limiting inefficient increases in health services expenditures. Thus, they face the common problem of obtaining sufficient knowledge to convince health care professionals and the public that they have the ability to eliminate less cost-effective procedures and control the pace of medical innovation. This series also illustrates how the economic differences between countries result in different resource allocations for health care expenditures. The case studies underscore the fact that health systems must mount a country-specific response to common health challenges. Thus, health care providers must provide the most cost-effective, equitable, and acceptable health care possible within the parameters of their society.^ieng

The Cuban health care system and factors currently undermining it.

This paper explores the dynamics of health and health care in Cuba during a period of severe crisis by placing it within its economic, social, and political context using a comparative historical approach. It outlines Cuban achievements in health care as a consequence of the socialist transformations since 1959, noting the full commitment by the Cuban state, the planned economy, mass participation, and a self-critical, working class perspective as crucial factors. The roles of two external factors, the U.S. economic embargo and the Council of Mutual Economic Cooperation (CMEA), are explored in shaping the Cuban society and economy, including its health care system. It is argued that the former has hindered health efforts in Cuba. The role of the latter is more complex. While the CMEA was an important source for economic growth, Cuban relations with the Soviet bloc had a damaging effect on the development of socialism in Cuba. The adoption of the Soviet model of economic development fostered bureaucracy and demoralization of Cuban workers. As such, it contributed to two internal factors that have undermined further social progress including in health care: low productivity of labor and the growth of bureaucracy. While the health care system is still consistently supported by public policy and its structure is sound, economic crisis undermines its material and moral foundations and threatens its achievements. The future of the current Cuban health care system is intertwined with the potentials for its socialist development.

PIP: The dynamics of health care in Cuba during a period of severe crisis was explored within an economic, social, and political context. Cuban achievements in health care since 1959 were a consequence of the full commitment to health care by the state, the planned economy, and mass participation. In 1959 the infant mortality rate was 60/1000 live births and life expectancy was 65.1 years. By the period of 1983-88 Cuba had attained an infant mortality rate of 15/1000 and female life expectancy of 76 years compared to the figures of 27/1000 and 73 years, respectively, in South Korea. In response to problems that arose in the 1960s an improved health care model stressing the involvement of health care workers in the community was proposed in 1974. In the early 1980s 20,000 family physicians were trained to provide primary care services in the communities. Two external factors, the US economic embargo and the Council of Mutual Economic Cooperation (CMEA), shaped the Cuban society and economy, including its health care system. The U.S. embargo forced Cuba to pay higher transportation costs to import medical supplies from Soviet-bloc countries. Once the Soviet bloc collapsed, Washington further tightened the embargo through the Torricelli Bill of 1992, which bars U.S. subsidiaries in other countries from trading with Cuba and forbids US portage for 6 months to any ship that has docked in Cuba. As a result, in 1993 Cuba's imports for public health cost an extra $45 million. The CMEA was an important source for economic growth; however, the adoption of the Soviet model of economic development contributed to two internal factors that have undermined health care: low productivity of labor and the growth of bureaucracy. Social expenditures declined from 70% of the GNP in 1970 to 36% in 1995. Meanwhile, administrative personnel grew from 90,000 persons in 1973 to 240,000 persons in 1984. In 1995 some 50,000 physicians were serving a population of 11 million. Since 1986 a total of 1042 individuals have been found to be HIV positive. The policy of forced isolation of HIV-positive persons and AIDS patients was relaxed recently. While the health care system and its structure is sound, the economic crisis undermines its material and moral foundations and threatens its achievements.

Fighting AIDS the Cuban way.

PIP: Cuba is using elements of classical public health practice in its national AIDS control program. Its AIDS policy appears to be successful. Cuba has 927 HIV-positive cases and 187 AIDS cases (111 deaths) in a population of more than 10 million. Its neighbors have cumulative AIDS prevalence rates at least on par with those of the US. Puerto Rico (around 3 million population) has more than 8000 AIDS cases. Cuba's health system provides for a family physician for every 12 apartment blocks. This physician lives in the community and makes home visits. Medical testing and screenings, including HIV screening, are routine in Cuba. Cuba has the most comprehensive HIV testing program in the world. This program detects fewer than 125 new HIV-positive cases annually. Cuba's successful health system existed before the advent of AIDS. More than 60% of HIV-positive persons are heterosexuals. Many were infected while serving abroad (internationalists) or as sexual partners of internationalists. Cuba considered AIDS as just another health threat and handled it accordingly. It did not worry about offending high risk populations. HIV-infected persons living in the HIV/AIDS sanatoria receive full salaries regardless of their work status and are expected to follow rules that serve to benefit themselves as well as Cuban society. They must accept the three safe sex commandments of the sanatoria before being allowed to leave after completion of a 6-month probationary period. Some patients are allowed to return home after the probationary period. Residents who practice unsafe sex lose their right to leave unchaperoned. All residents receive an individually tailored regimen, which regimen includes exercise, interferon or AZT, and a high calorie and protein diet (5000 kc/day). The Cuban AIDS program focuses on protecting gays, women, and children.^ieng

Chile averts measles outbreak.

PIP: Chile is the first mainland country in Latin America to have arrested epidemic transmission of measles virus for more than 18 months. The health ministry successfully averted an imminent outbreak of the measles virus. Health personnel knew that the 2- to 3-year epidemic periodicity of measles meant that an outbreak could be expected in 1992. Although coverage levels had hovered around 90% since the last epidemic, an outbreak could occur among those who had not been vaccinated in that period or those who failed to seroconvert. To prevent an outbreak, health authorities decided to organize a National Campaign that would vaccinate 95% of all children aged 9 months to 14 years old (3,930,000 children) in 2 weeks. 99.6% of the children were immunized with a standard dose, regardless of their previous vaccination history. Post-campaign epidemiologic surveillance of rash and fever illness was carried out from April 17, 1992 with the organization of laboratory diagnostic capabilities. Compliance with the probable measles case definition nearly doubled between 1992 and 1993, and the proportion of probable measles cases for which blood samples were taken increased from 64% to 79% for the same period. Compatible cases declined from 8% to 5% between 1992 and 1993. From the time the campaign was organized to the end of 1993, only 2 imported cases of measles were confirmed. Chile's experience offers several useful hints for other countries, particularly setting up a system for the active surveillance of rash and fever illness. The measles surveillance case definition must be disseminated and the critical clinical information for each case must be reported. Priority should also be given to ensuring that adequate blood samples are taken before a case is discarded. The final diagnosis for a large percentage of probable cases was determined by laboratory analysis. Surveillance means vaccinating all susceptibles as soon as a probable case is reported.^ieng

Cost-benefit analysis for the use of Haemophilus influenzae type b conjugate vaccine in Santiago, Chile.

Cost-benefit analyses can be integral to the evaluation of interventions in developing countries. The authors compare the potential benefits to the Chilean Ministry of Health, in terms of treatment costs averted, by prevention of Haemophilus influenzae type b (HIB) invasive disease, with the costs of adding HIB conjugate vaccine to the diphtheria-tetanus-pertussis (DTP) immunization routinely administered to infants. In their basecase model, over a 10-year period (1991-2000), vaccination against HIB will prevent 1,229 cases of HIB invasive disease, including 713 cases of meningitis, 107 of whom would suffer severe, long-term sequelae, and between 29 and 116 deaths. Assuming a cost of US$1 for a full three-dose regimen of vaccine, the benefit/cost ratio of 1.66, with a net discounted savings of over $403,225, illustrates that HIB vaccine can be cost-beneficial. Sensitivity analyses which alter each of the variables in the analysis indicate that if the true incidence of HIB disease is twice the published rate, then three doses of vaccine remains cost-beneficial at US#3.

PIP: Health practitioners reviewed the clinical records of all 6-60 month old children who were treated for meningitis caused by Haemophilus influenzae type b (HIB) in 1989-1990 at Roberto del Rio Children's Hospital in Santiago, Chile, to estimate costs for all phases of meningitis treatment (ambulatory visits, hospitalization, and follow-up). They also estimated annual HIB incidence. They determined the cost of adding HIB conjugate vaccine to the DTP vaccine. They assumed a cost of US$1 for a full 3-dose regimen of vaccine. They then conducted a cost benefit analysis of the use of HIB conjugate vaccine to prevent invasive HIB disease in Santiago. The National Health Service had to pay an average of US$1301/case of HIB meningitis and US$887/case of HIB invasive disease other than meningitis, including pre- and post-hospitalization costs and adjustment for frequency of sequelae. Several factors indicated that the estimates were actually underestimates. For example, the researchers did not take into account herd immunity and the fact that sequelae often do not appear until the children are older. The addition of the HIB conjugate vaccine to the immunization program would prevent at least 1229-3111 cases of HIB invasive disease, disabling sequelae, and deaths during a 10-year period. Further, it would save the National Health Service more than US$403,225. The benefit/cost ratio was 1.66. The researchers changed each of the variables in the cost benefit analysis. These sensitivity analyses revealed that if the true incidence of HIB disease were 2 times greater than the based on reported data, the 3 doses of HIB conjugate vaccine would still have a cost benefit of US$3. These results indicated that adding HIB conjugate vaccine would exert a considerable public health and cost benefit. Cost benefit analyses of vaccines would also prove useful to decision-makers in other developing countries.

Struggle against injustice.

PIP: For more than a decade, striving to implement equitable health systems has been fundamental to improving the health of populations, yet in the poorer countries of the world, things age getting worse in terms of people's health and access to health care. An estimated 1600 women die every day from complications of pregnancy or childbirth, since less than 20% of deliveries take place under the supervision of trained personnel compared to 99% in industrialized countries. In africa south of the Sahara, 100 million clinical cases of malaria are reported every year resulting in close to 1 million deaths. The problem is worse than it was 10 years ago. The resources, money, and political will to tackle prevention and control are lacking. For the first time this century, a cholera epidemic broke out in Peru with almost 250,000 cases in the first 6 months of 1991. 12 African countries also suffered serious outbreaks with case-fatality rates of 10-12%. In almost all countries of the world, the gap between the rich and the very poor continues to grow. In the USA, it is estimated that 1/4 of the population does not have proper access to health care owing to the rising costs of health insurance. The false impression that health is the exclusive concern of medical workers has been encouraged by the health professions for decades. Most countries do not recognize the needs of the poorest groups in their societies. It is necessary to encourage and teach people to prevent disease by promoting good health practices, to care for the sick and dying, and to exert pressure to win commitment and action on behalf of those in need.^ieng

Cuban health system -- call it superior?

PIP: In a response to an article by Benjamin and Haendel on the Cuban medical system (Links, Fall 1991), A.F. Brown criticizes the 2 authors for failing to call the Cuban medical system by its rightful name: superior to that of the US. According to Brown, Benjamin and Haendel's own data bear out the fact that Cuba has a better medical system than the US. Life expectancy is 76 years in Cuba compared with 75 in the US. Doctor/patient ratio is double that of the US. In 1990, there were no measles cases in Cuba compared with 25,000 cases in the US. In Cuba, there is 100% prenatal care coverage and hospital delivery; abortion is free and available on demand; and immunization rates are nearly 100%. As Brown explains, the 2 authors omit an important feature of comparison between the 2 systems: in Cuba there is free and universally available medical care, while some 35 million US citizens lack any health insurance. In their article, Benjamin and Haendel describe Cuba's response to the AIDS epidemic--mass testing for HIV and confining all seropositive cases--as draconian. But according to Brown, the fact that Cuba's rate of infection is 0.19/100,000 compared with a rate of 13.88/100,000 in the US validates the policy. Brown also dismisses criticism that there are too many doctors in Cuba, that nurses have a low status, and that such physician-heavy system is not cost-effective. Failure to acknowledge the superiority of the Cuban health care system, Brown maintains, reflects an attitude that such a system is too good for them--and better than ours.^ieng

The use of rectal tubes for stool collection.

PIP: Besides verifying the absence of wild poliovirus transmission in children with acute flaccid paralysis, the ICCPE also advocates verifying the absence of wild poliovirus transmission in the environment. This can be done either by community stool surveys of normal children or by sampling sewage. In developed countries, the sampling of sewage tends not be a constraint since adequate sewage systems exist. In developing countries where such systems do not always exist, or, if they do, they do not always operate, community stool surveys are preferable, especially in remote rural areas. In April 1991, staff from PAHO and the Ministry of Health of Colombia conducted a community survey of 242 5 year old children living in a high risk area of Cartagena, Colombia to compare the effectiveness of the traditional cup technique of collecting stool samples with the polyethylene rectal tube in screening normal children 5 years old. They chose this area of Cartagena because it has had several confirmed cases of polio. The rectal tube was to be inserted 66-75% of its length into the rectum. More children had their stools collected via the traditional cup technique than the rectal tube technique (67% vs. 36%; p.001). Isolation rates for enterovirus including poliovirus were similar for the 2 techniques. Thus the probability of getting stool samples from children 5 years old was 3 times greater with the traditional cup technique than the rectal tube technique. In fact, the collection rate for the rectal tube was so low, staff could not accurately evaluate the possibility of silent transmission among high risk children. PAHO advises then that health workers not use the rectal tube in the polio eradication program in the Americas until further research has been conducted.^ieng

Jamaican measles surveillance system.

PIP: In 1991, the Ministry of Health and technical consultants from PAHO evaluated the measles surveillance system in Jamaica. This system consisted of the notification system, the sentinel sites system, active hospital surveillance, laboratory reporting, and special surveys. The team concentrated their efforts on the system's ability to detect and investigate suspected cases of measles. The team visited sentinel sites including health centers, hospitals, or a physician in all 13 parishes. 44 sites operated at the time. It spoke with medical Officers and Senior Public Health Nurses and evaluated written records. The notification system had recently classified measles as a Class I disease to encourage a rapid public health response and to secure investigation records. The major weakness of the notification system was case investigation. In 1991, health workers investigated only 6 (3%) of 208 suspected cases within 48 hours and eventually investigated only 76 (36.5%). 23 cases were confirmed as measles. Serology tests revealed that most suspected cases were actually rubella. This indicated a need to include serological testing for confirmation. The team found that the notification system underreported cases. Each sentinel site was required to collect each week a count of the number of cases of measles and other conditions to monitor trends. 87% reported the counts weekly. The sites consistently reported measles bas ed on clinical suspicion. Public health staff visited hospitals weekly to review cases of target disease including measles. They visited at least 1 hospital regularly in each parish. Hospital records did not contain consistent measles data. For example, only 10 of 13 visit reports included patient's name, age, sex, and address and only 7 included outcome. Detailed information was only available on 13 of the 208 suspected cases so the team was only able to evaluate them.^ieng

Why Nicaraguan children survive. Moving beyond scenario thinking.

PIP: The authors respond to Tony Dajer's critique of their study concerning the trend in Nicaraguan infant mortality and its possible explanations. It is pointed out that the sharp decline in Nicaragua's infant mortality in the mid-1970s is an intriguing phenomenon, since it began to occur at a time of economic slump, civil disturbance, and under a government that gave low priority to the social sector. It is contended that a number of factors (among them the Managua earthquake) prompted the government to shift its allocation of resources from hospital-based health care in the capital city to ambulatory health care throughout the country. After the revolution, the Sandinista government continued this process. Dajer's characterization of USAID-funded clinics as "notoriously ineffective" is rejected; arguing that although operating under overt political guidelines, these projects are well-advised by experts. Dajer's question as to the importance of health care within the Sandinista government is considered. It is maintained that the revolution was not fought in order to reduce infant mortality, and that health was not the primary concern of the Government of National Reconstruction. It was the international solidarity movement, not the Sandinista government, which focused so intently on infant mortality, hoping to find good news to report. The issue of health care had the added advantage of being politically noncontroversial. It is also maintained that since the mid-70s, the country's health policy has remained stable, despite the radical changes in government because the international arena helps determine national health policy.^ieng

Cuba. A healthy revolution?

PIP: Discussing Cuba's remarkable accomplishments in health care, this article considers the cost of maintaining such a system at a time of economic hardship. Following the revolution of 1959, Cuba has achieved immense advances in health care. Today, its infant mortality rate if the lowest in Latin America and at par with industrialized countries. Its life expectancy is actually higher than that of the US. At 1 doctor for every 297 inhabitants, Cuba has one of the highest ratios in the world. Furthermore, the island nation has created a pharmaceutical industry that supplies 80% of the country's needs, and has a developed high-tech medical techniques which rival the best in the world. And beginning in mid-1980s, Cuba began the Family Doctor Program, in which a physician lives and works in the neighborhood and acts as a public health advocate, while remaining part of the larger health care system. The program has been very popular with the population, and evidence suggests that the program has been highly successful in reducing infant mortality, the number of emergency room visits, and the average hospital stay. Despite its remarkable success, Cuba's health care system does attract criticism. Some charge that Cubans are "over-medicated," and that Cubans no longer take responsibility for their health. Also, some charge that the country has too many doctors and not enough assistants, nurses, and midwives. These criticisms have become even more pointed, as the country's economic crisis deepens. People complain about the scarcity of food. And due to drastic cuts in Soviet aid and the US blockade, Cuba has been forced to impose severe austerity measures. While the authors believe it unlikely that Cuba will be able to maintain its health care system, they say that ending it will be tragic.^ieng

Women and AIDS. What shall we do with these Uruguayan girls?

PIP: A dilemma exists over who should care for, and where to place 4 delinquent female runaways with AIDS. These girls have also engaged in prostitution, crime, and are addicted to drugs, thus prompting society to view them more as dangerous adults than aberrant adolescents. While they are presently in the hands of the National Institute for Minors (Iname), organizations in Uruguay are ill-equipped to face such challenges presently by these and other HIV+¿AIDS adolescents. Discussion of the issue and society's views is suggested. The views of a few civil servants from Iname are briefly presented in the text. They generally disagree with incarceration of such youths, and recommend there placement in a semi-open environment supported by specially trained doctors, psychologists, psychiatrists, and nurses. Ideally, a home-like setting is preferred where these young women and others in similar situations may undergo treatment while carrying on with their lives.^ieng

Socioeconomic development, health interventions and mortality decline in Costa Rica.

Costa Rica, whose life expectancy was 74 years by 1985, has reached a health level comparable to a developed country. The health achievements of this country are product of political and socioeconomic circumstances as well as of right public health policies. Until about 1970 the features of Costa Rica mortality, although somewhat better than the Latin American average, evolved in a similar way to the rest of the region. In particular, the decades of 1940s and 1950s saw dramatic improvements in life expectancy, thanks mainly to the import of low-cost, high-effectiveness health technologies. In the 1970s, however, Costa Rica departed from a regional pattern of stagnation and managed to close the gap with developed countries in terms of mortality levels. A dramatic decline in the infant mortality rate from 60 to 19 per 1,000 took place in this decade. The main determinants of this breakthrough were health interventions, notably a primary health care program, even though favorable socioeconomic conditions and a reduced fertility also played a role. Ecological data and other evidence suggest that up to three fourths of the mortality decline was accounted for contemporary improvements in public health services, with about 40 percent attributable to primary health care interventions. Furthermore, by targeting interventions on the less privileged population, these interventions had the merit of reducing geographic and socioeconomic differentials in child mortality.

PIP: This is an historical survey of the reasons for the rapid increase in life expectancy and decline in infant mortality in Costa Rica in this century, with regression analysis of determinants of infant mortality. Costa Rica, although a small, relatively poor Central American country, has as of 1985 a life expectancy of 74 years and infant mortality rate of 19/1000. Some of the general social features contributing to its success are racial and cultural homogeneity, constitutional renunciation of an army, a social-democratic welfare-oriented government since the 1940's and a universal education. In recent decades institutional reorganization included formation of a Central Sanitary Office in the Ministry of Health, a Central Assistance Office, and a Social Security System providing medical and hospital care. In the 1970s all hospitals were placed under Social Security. Now 98.9% of hospitalizations are covered, and 7% of the GDP goes for health care. The epidemiological transition began gradually with sanitation and economic growth in the early 20th century and accelerated with the advent of antibiotics, vaccines, and DDT in the 1940s and 1950s. After a stagnant period in the 1960s due to volcano eruptions, the 1970s saw vast improvements in education, communication, and health infrastructure resulting in control of malaria, tuberculosis, helminthiases, tetanus, measles, diarrheal and respiratory infectious deaths. In the 1970s, primary health care, in the form of quarterly home visits to disadvantaged rural and urban areas, equalized health indices across the country. Immunization reached 95% an sanitation 96% of homes. Secondary health care (outpatient) was extended under Social Security. In this era, fertility fell by half, primarily due to birth spacing and limiting of higher order births. Regression analysis shows that primary health care accounted for 41%, secondary medical care for 32%, socioeconomic progress for 22%, and decline in fertility for 5% of the fall in infant mortality.

Learning from the Third World: health care in Nicaragua.

PIP: In this article, Candace Kugel, a family nurse practitioner in Pennsylvania who visited Nicaragua as part of an exchange program, describes her impressions of the country's health care system. Kugel is a member of the Project Gettysburg/Leon, a sister-city program that promotes cultural exchanges. She arrived in Nicaragua less than 2 weeks after the newly elected UNO government assumed power. In Leon, Kugel visited seven rural and urban clinics, the city's hospital, the health education organization, and the medical, dental, and nursing schools. In all health facilities, she discovered politically energized and committed health care workers. It is this determination that allows then to continue working in spite of perpetual shortages of even the most basic supplies. The hospital was out of insulin, and was having to reuse bulb syringes for newborns. One clinic lacked water supply. Kugel also found nurses to be in short supply. As she explains, the physicians outnumber professional nurse 3-1. Because of low salaries, 1 6-day work schedule, and staffing shortages, few are interested in becoming nurses. Furthermore, the nursing school is severely ill-equipped. Nonetheless, Nicaragua's health care system has accomplished health: immunization, family planning, prenatal care, well-child screening, health education, and treating open water for malaria and dengue-bearing mosquitoes. From 1979-88, infant mortality dropped from 93/1000-62/1000, and life expectancy increased from 56-63.3 years. Additionally, Nicaraguans now consider health care a right, not a privilege. Kugel hopes that with the end of the US embargo and the renewal of US aid, Nicaragua will accomplish even more.^ieng

We are all people living with AIDS: myths and realities of AIDS in Brazil.

Although AIDS was expected in Brazil, no serious efforts were undertaken to prevent AIDS from taking root. Irresponsible press and media coverage highlighted the spread of AIDS within the gay community of the United States, creating an aura of immunity in Brazil to what was characterized as a "foreign" disorder. When AIDS did surface in 1983, the official response was to adopt an abstract, inappropriate, and ideological "Western" model, in which only stigmatized "others" and "minorities" were at risk of HIV infection. Brazilian health authorities subsequently downplayed the significance of the sale of contaminated blood in HIV transmission, and likewise ignored the rising rates of AIDS among Brazil's one unarguable majority group: the poor. An analysis of efforts to force the "facts" of AIDS to fit a false model's predictions leads to a clearer definition of the broader context of the Brazilian epidemic: we all are people living with AIDS, precisely because we live in this age of AIDS; it is sheer folly to discriminate against persons infected by HIV and to obstruct their participation in efforts to curtail the epidemic's spread; and the necessary response to AIDS is solidarity, not because it is poetic, but because no other response will suffice.

PIP: Despite general public and administrative awareness of AIDS since 1982, virtually nothing has been done by the Brazilian government to check its epidemic spread in Brazil. Press reports, especially in the early days of AIDS, were a mixture of reports covering the U.S. experience with AIDS and yellow journalism designed to fuel public debate, controversy, and spending on medial consumption. This mixed image of the epidemic helped portray AIDS as an affliction to others, enigmatic and somewhat exotic. Though AIDS was expected to arrive in Brazil, complacent, unconcerned officials responded in a lackadaisical manner through the veil of an abstract, inappropriate, and ideological Western-oriented model. Failing to recognize the imminently board spectrum of sexual orientation prevalent in Brazil, and in contrast to that of U.S. society, Brazilian officials tried to classify Brazilians into the easy, accepted categories of homosexual, bisexual, and heterosexual as assumed in North American and Europe. Blood supplies were eventually tainted out of this failure to take constructive action, with the resultant mass infection of segments of the Brazilian population. This author is angry with Brazilian public and private attitudes at the lowest and highest levels of administration, and indicts the bureaucratic system created by his society. Complacency, ignorance, and social discrimination have resulted in countless deaths, and continue to incur great economic costs and mortality. He calls upon society to re-examine what living with AIDS is all about, how it affects society as a whole, and recognize the crucial need to fight the war on AIDS with solidarity as a united, committed whole. AIDS is not a problem afflicting limited minority groups; it threatens major economic breakdown, especially in 3rd World countries, in the absence of universal cooperation between those infected, and those who would otherwise consider themselves immune.

Cuba's health care policy: prevention and active community participation.

In Cuba, health care is considered a human right for all citizens; health care is therefore a national priority. Cuba's health policy emphasizes prevention, primary care, services in the community, and the active participation of citizens. These emphases have produced an impressively high ranking on major health indicators, despite economic handicaps. The Cuban experience demonstrates the influence of ideological commitment and policy-making on the provision of health care and challenges the assumption that high-quality care for all citizens requires massive financial investment. The evolution of the Cuban health care system since the revolution thus has implications for the U.S. health care system; specifically, it suggests that the equitable distribution of health care services in the United States requires a national health insurance and service delivery system.

PIP: The new Cuban government in 1959 began overhauling the for-profit health system which, 30 years later, resulted in free health services for all its citizens which is integrated with national social and economic development. Life expectancy in Cuba is higher than that of the US (72.5 vs. 71.9). Health workers have eliminated polio, tuberculosis, typhoid fever, and diphtheria. Malnutrition incidence amount 1-15 years olds is 0.7% compared with 5% in the US. The Cuban health system began in the 1960s as a curative system based in hospitals but shifted during the 1970s and 1980s to a primary health care system based in communities. It consists of 6 hierarchical, interlocking levels: national health institutes and hospital centers (quaternary care-super specialty), provincial hospitals (tertiary care-high specialty), municipal hospitals (secondary care-specialty), area health centers (primary or community care) serving 25,000-30,000 people, sector polyclinics serving 4000-5000 people, and minipolyclinics served by a family physician team (family physician, nurse, and social worker) covering 600-700 people. The family physician team strategy has strengthened disease surveillance and completed information about health status and characteristics of neighborhoods. Neighborhood residents determine their own health care and protection. In fact, volunteer brigades build minipolyclinics and housing for family physicians and nurses. Critics of the Cuban health care system claim that the physician-to-population ratio is too high and that it makes up too much of the gross national product (almost 15%). Yet even though the US health system is the largest industry in the US and it has achieved impressive technological advances, the health of millions of US citizens deteriorates. The US needs a system that provides just, equitable, and quality health care to all. Thus US social workers should actively work toward national health insurance and on service delivery models.

Cuba: on the road to a family medicine nation.

Beginning with an overview of developments during the last 30 years, this article focuses on the current Cuban plan to convert the country into a family practice nation by creating a new primary care system. The new system is based on the training and placement of no less than 20,000 family physician and nurse teams by 1992. Cuba has come a long way in 30 years, as demonstrated by major health indicators.

PIP: Cuba has established a free, comprehensive, and accessible national family medicine based health care system. Since Castro came to power in 1959, the government has consistently been committed to improving living conditions, the health status of the population, and the national health system. For example, the prerevolutionary self financed health care system which served only about 20% of the population has 242 clinics and hospitals. By 1987, the health system which served the entire population had 263 hospitals and 159 social service units both of which has beds, 422 polyclinics (local health centers established in the early 1960s), 256 urban and rural medical posts, 160 dental clinics, 135 maternity homes, 22 blood banks, and 12 national research institutes. Some of the 1st macro-level actions of the Castro government entailed reducing the prices of medicine along with apportioning their importation, distribution, and production; reorganizing the national health system (MINSAP); and nationalizing all private health facilities and merging them with MINSAP. By the early 1970s, the population expressed dissatisfaction with the polyclinics, however. So, in 1974, MINSAP launched its primary care model based on addressing the interactions between the biological, social, economic, and cultural influences on community health. In spite of this change, not all of the expected improvements occurred. In the early 1980s, MINSAP created a new specialty based solely on providing primary care--the family physician and changes the medical school curriculum to incorporate family medicine. Presently a primary care team (1 family physician and nurse) cares for 600--800 individuals and lives and works in the area served. Surveys and other measures indicate that the communities are pleased with the primary care model.

[Brazil: the problem of human resources in the health district]. / Brasil: a questão dos recursos humanos no distrito sanitário.

PIP: Since the mid-1970s, the reform of the Brazilian health care system had been proposed by social and political leaders, who wanted to democratize and decentralize it, and in 1986 a health care reform project was accepted at the 8th National Conference on Health. A commission created to this end suggested the formation of health districts, as local units of the health care system. Their objectives included universal care, and the assurance of equal access to health care. The remuneration of different categories of recruited human resources within the districts posed a major problem: how to set up a system that would consider different levels of professional skills and education as well as retain incentives for lower echelon workers. The work regime which included repetitive, tedious, and alienating forms of activity presented another obstacle. Appropriate equipment was needed for biomedical professionals, for dentists, psychologists, nutritionists, and physiotherapists. The concept of general practitioner emerged, although the Cuban practice of assigning 1 physician for every 60 families could not be replicated in Brazil because of the lack of physicians. The maintenance of specialized services (internal medicine, pediatrics, surgery, odontology) in urban districts of cities with 150,000-300,000 inhabitants also confronted proponents of the reorganization. Thus, a new model uniquely suited to local and national realities had to be devised that would effectively satisfy the health care needs of the Brazilian population.^ieng