Health and Health Care In Cuba:
The Transition from Socialism to the Future
 
Antonio Maria de Gordon


 


Executive Summary

Health issues have played an important role in the history of Cuba. Issues dealing with nutrition and survival were evident in the Spanish conquest. Infectious diseases were a determinant factor throughout the Spanish colonization and the First American intervention. It is therefore important to consider health and health care issues during the transitional process that is bound to occur in Cuba after four decades of socialist, monopartisan, and authoritarian rule.

Notwithstanding Cuba's health and health resources in 1959, health and health care during the revolution have been recognized and propagandized as major achievements of the revolutionary experience. Beyond any perceptions that may be prevalent outside of Cuba, it is important to appreciate that the Cuban people have been trained during the revolution to have access to health care and to expect appropriate health care. These expectations, despite important issues in terms of costs, resources, and organization or services, must be made a priority in order to effectively carry on, an probably improve health services during the transition and beyond:

The Cuban population is mostly young with nearly 22% of the people being younger than 15 years of age. Cuba had in the year 2000 the highest percent of population older than 65 years of age in the region. While the thrust of the health policies during the transition must address the needs of the young, attention must not be denied to the other end of the age spectrum.

Life expectancy has been increasing and infant mortality have been decreasing in Cuba. However, general mortality has increased appreciably. In the context of the transition, it is advisable to review all data gathering practices and policies of Cuba. This is the more important when one recognizes that the Cuban health services are under strong political control. Future evolution of Cuba's health services must be depoliticized, that is, taken out of the direct control of political parties.

The development of Cuban health services coming out from the current authoritarian, politically controlled administration cannot be left to chance. The spectrum of variables that have been reported by the countries in Eastern Europe suggest that proper planning be considered in terms of health services. The health priorities and the transition process must be organized and directed with a flexible but workable agenda. The goals for health care during and after the transition should include these following points:


a. A health services with access guaranteed to all.
b. A health service administered independently of political parties.
c. A health service administered with representation of the medical and other
health care professions, patient representatives, and legislative representatives
or the equivalent.


The transition process must include the provision of emergency services and a safety net for health and nutrition. The latter may be accomplished through a number of logistics.

However, there must be a goal to eventually evolve the "libreta de racionamiento" into the ability of most Cubans and Cuban families to obtain their nourishment without the requirement of the safety net.
Diseases that appear to be important in Cuba are cardiovascular disorders, cancer, diabetes, alcoholism and mental illness. Attention to all common disorders must be addressed. The prevalence and seriousness of asthma and hepatitis are increasing in Cuba. Proper environmental controls, provision of adequate hygiene and access to care will be important in the care of Cubans suffering from these medical morbidies. Cuba has become an important member of the WHO. During the transition and beyond, the role of Cuba's involvement in WHO activities should increase. It should be important to share with WHO and WHO countries the advances used in Cuba.

The use of the media in health care and health services should become routine. These services should be noncommercial providing a medium where the people could communicate with professionals thusly obtaining proper orientation and advice.

The investments made by Cuba in the field of biotechnology have surpassed 800 million dollars. Although Cuba is able to produce a limited number of biotechnology-produced vaccines, other countries in the region are indeed the leaders in this field.

It should be possible during the transition, however, to harness the vast investments and facilities in terms of both physical plant and human resources. Consideration should be given, in the setting of depoliticization of health services, to timed leases of certain biotechnologic facilities to private global companies involved in the production and development of drugs, diagnostics, and vaccines. These negotiations may provide a scenario where Cuba's resources may be made profitable rather quickly into the transition. At the same time, these negotiations must never be seen as a give away by
Cuba of valuable health resources.

In summary, Cuba's gains in health and health services have been accomplished through a system that is authoritarian and highly politicized. Progress through the transition out of this particular system of government requires study, planning, and organization so that health services - already considered important by the Cuban people -are maintained and improved through the transition in the near future.

Top

Introduction and Historical Background
Health has been an important factor in Cuban history. From the moment that the Spanish discovered the island, conquered it and began to populate it through settlements and migrations, health occupied a preeminent role in Cuban affairs. Among the factors that lead to such disastrous consequences for the Cuban Indians was the Spanish diet of the XV and XVI centuries.(l) The latter contained a very high content of saturated, animal fat estimated at 40% of the caloric intake.(2) This figure is three to four times greater than the estimated fat content of what may be called, the Cuban aboriginal diet. Health and nutrition were important factors in the extermination of the Cuban aborigines.

Health issues, particularly the epidemics of tropical fevers, proved the determining factors in the decision of the British to exchange Eastern Cuba for Florida in 1672. Many years later, at the end of the XIX Century, health issues occupied an important position in Cuban history. (3) Yellow fever was rampant in Havana during the XIX Century. In fact, yellow fever was the most dreaded of the various fevers that preferentially attacked newcomers and immigrants to the island.(4) Obviously, these tropical epidemics attacked the fresh Spanish soldiers brought into the island to put down the forces of Maceo and Gomez. The fevers also attacked the legends of American soldiers and sanitary personnel that arrived in Cuba. The fevers continued to attack during the first American intervention. From the military medicine standpoint, the Cuban theater of the war was relatively short resulting in 332 Americans dead.(5)

Immediately after the conclusion of the Spanish American War, journalists were reporting about 320 to 430 victims of yellow fever monthly. About thirty percent of these casualties died because there was no specific treatment for yellow fever.(6) It can be argued that one factor that led the United States to quickly pass the responsibilities of government to the Cubans was the perilous state of health in the island, i.e., the continued emergence of the epidemics of yellow fever. The Platt Amendment, an American amendment demanded to be added to the Cuban Constitution of 1901 by the Americans at the conclusion of the Constitutional Convention, included among several points, issues related to health and epidemic diseases.

In the context of these important political issues, Dr Walter Reed was assigned to head a commission to investigate yellow fever in Havana. After reaching a number of epidemiologic "dead-ends", Reed's commission sought information about the theories and experiments of Dr. Carlos J. Finlay. Soon, the theory advanced by Finlay regarding the transmission of yellow fever through a vector, the Aedes aegypti mosquito, was tested in the Columbia barracks near Havana. After proper implementation of public health measures essentially described by Finlay in 1881, (4) the mosquito population was controlled by William Gorgas. Havana was literally free of yellow fever in a matter of three months.

Cuba's health continued to improved through the first half of the XX Century.(7) By 1920, various writers were documenting the fact that Cuba was a safe country in matters of health. Cuba's health parameters at the conclusion of the 1950's were notable in Latin America suggesting that Cuba was indeed able to generate and implement effective health care.

Life expectancy at birth is an important health parameter because it is easily observable, it can be used in demographic comparisons and calculations, and it is a function of various important factors such as living conditions, access to health care, nutrition, and prevention of various common diseases. Life expectancy in Cuba was of the order of 60 years in 1950. Note that at that time in history, life expectancy was 70 years of age in Western Europe and 67 years of age in Eastern Europe. The average life expectancy in countries of the so-called Third World was of the order of 40 years of age. The demographic transition from rural to urban centers occurred in Cuba about 20 years before it happened in the average country of the Third World.

It is evident that among the various regions where developing countries are grouped, that Cuba's position was and is a relatively favorable one. It is also important to argue in favor of maintaining Cuba's lead in this and other health parameters during the current crisis and in the future.

Hence, it is not surprising that life expectance and other health related parameters in Cuba were better than in the average country of the Third World.


 Table 1: Life Expectancy (yrs of age) in Cuba and Various Regions of the Third World. (8)

  

1955

1970

Cuba

63

71

Other Latin American Countries

52

62

Asia

43

56

Africa

37

48

The Cuban revolution of 1959 led to an alignment of the island to the Communist block. The Castro regime assumed an increasing role in the government and politics of the island. Although Cuba had various health regulatory controls in place prior to 1959, these were literally overwhelmed by the control exercised by the State with the advent of the revolution. All aspects of Cuban society under the 44 year old rule of Castro - from the agricultural, education, military, urbanization, etc, to health and health care - have became centralized, socialistic, and officially part and parcel of the government.

Since the revolution, Cuba has been recognized in many circles including the United States Congress, the World Health Organization, and the Pan American Health Organization (9) as a model in State planned health service and for the delivery of health care.
A widely recognized problem in Cuba before the revolution was the access to health care. (10) The health access problem during the 1950's was summarily corrected during the early revolutionary experience. Although the total number of physicians in Cuba in the beginning of the revolution was somewhat adequate, approximately 6,600 doctors for a population of 6 million Cubans, their geographical distribution was not optimal. The discrepancies are evident from the data below (Table 2)

Table 2: Health Access in Cuba: Physicians and Hospital Beds, 1953. (11)

Province

Physicians
per Inhabitant

Beds per Inhabitant

Habana

1 per 420

1 per 82

Pinar del Rio 

1 per 2,100

1 per 1,045

Oriente

1 per 2,500 

1 per 545

In 1953, 62.5% of physicians in Cuba worked and/or practiced in Havana. Ideally, the number of physicians in the capital city of a country should be proportional to the population residing and working in the capital. In numerical terms, one can define a 'distribution ratio' defined as the ratio of the percent of physicians who work in the capital to the percent of the population who resides and/or works there. (12) Ideally, this "distribution ratio" should be of the order of 1.0 meaning that the percent of doctors in the capital is identical to the percent of the population that resides and works there. In Cuba, however, the "distribution ratio" was 4.0 in the 1950's. By 1980, under the revolution, the "distribution ratio" was of the order of 1.2. The latter is obviously considered a more favorable parameter than the former. However, the numerical ratio does not include into the equation various individual freedoms, a competitive market economy, individual professional goals of young doctors, or separation of families and communities.

Before 1959, most physicians worked for the State or Province and also worked in private practice in various hospitals, clinics, and "consultorios". To be sure, the Constitution of 1940 provided a framework for regulations of the professions and the organization of a national and regional medical association (Colegio Medico Nacional etc.) All physicians were expected to be members of the latter and follow working, practice and ethical guidelines. The leadership of these institutions of professional regulation and quality control were democratic and all members were expected to participate in decisions from the grass roots to the top of their leadership in decision-making.

These regulatory agencies changed drastically in the early years of the revolution. The Colegio Medico National (13) and all regional organizations disappeared or went into exile. All Cuban medical graduates since the revolution became technical workers of the Ministry of Public Health (MTNSAP). They were also prohibited by law to engage in any professional, medical activities outside their official work description and sphere influence.

The distribution of hospital beds was equally uneven before the revolution (11) (Table 2) . There was also great variability and reliability in the access to any type of health care as a function of geographical location or rural versus urban centers. Most observers agree that the administrative and coercive measures taken by the totalitarian revolutionary government in order to achieve a nearly ideal distribution of physicians are undesirable and possibly unnecessary. However, these are complex issues which require study, discussion and assessment in the context of all aspects of Cuban society that are facing to undergo a transition process towards a more open, less blatantly coercive society.

Access to health care was variable in pre-revolutionary Cuba. However, Cuba was one of the first countries in the Western hemisphere to establish a social security benefit to attend health care needs. (7) Since the establishment of the Cuban Republic in 1902, health services were traditionally left to the provincial and municipalities governments. These official institutions usually maintained centers of immediate care known as "Casas de Socorros" (14, 15) The effectiveness of these centers varied depending on the funding available. Their number in 1958 was of the order of 200 centers for the 126 municipalities that existed in Cuba then. In the major urban centers including Havana and the provincial capitals, however, there were also several public hospitals dedicated to maternity, pediatrics, and general medicine.

The Cuban social security provided up to 1958 two types of risk protection: workman's compensation and maternity. Workman's compensation programs began in 1916. By 1933, the program was widely used whereby employers insured employees through one of several insurance companies.

The maternity program began in 1934. It was financed through contributions from both the employees and the employers. The benefits included medical and obstetrical attention during the pregnancy, through the puerperium, and post-partum. The funding of this program allowed many urban centers to build maternity hospitals and outpatient facilities for the care of women.

In 1950 there was a brief period when health insurance was available for some workers. The "Caja del Retiro Global Azucarero"(Sugar Workers Insurance Fund) was founded. The insurance covered disability, death, and health services. The health services included medical and dental care, inpatient and outpatient services, non-work related accidents benefits, and medications. The plan was probably too ambitious for the funding and structure that was envisioned. Very soon it was abandoned in the period of time when the Constitution of 1940 was essentially abolished in early 1952 through the "coup d'etat" that took Fulgencio Batista to power.

The best known of the health care delivery institutions of Cuba prior to the revolution were the mutualist medical centers (MMC). (15) These were not for profit organizations that owne and operated health care facilities. They originated in Cuba towards the latter part of the XIX Century. They arose from several ethnic Spanish groups, the Galicians, the Asturians, etc. The MMC's covered large groups of beneficiaries and their relatives.

Each beneficiary paid monthly dues, of the order of 2 to 5 Cuban pesos per person. All medical services were received and rendered at the institutions themselves. The costs of operating the facilities were the responsibility of each of the MMC's. All beneficiaries participated directly or through elected representatives in committees in the management of the MMC in the decision making process. That is, beneficiaries or their representatives were present in managerial and professional commissions where decisions were made regarding guidelines, practices, ethics, equipment, medications, benefits, etc. The MMC's also provided in many instances other educational and social services such as schooling, training in the trades, recreation and sports. It is estimated that less than half of the population in Havana belonged to one of the MMC's.

In the 1940's, another type of health care organizations began to spring up in Cuba. The so-called "medical cooperatives"(MC's) were formed by physicians. These organizations were not necessarily not for profit. The beneficiaries signed up for their sendees and paid monthly dues. Health services were probably equivalent to those provided by the MMC's but the beneficiaries in the MC's were not - directly or through representatives-participants in the management and decision-making process of the organizations.

The other sector of Cuban society that had medical benefits for themselves and their families was the military. Since the early XX Century the Cuban Army maintained military hospitals and outpatient facilities in all six Cuban provincial regiments. A new central military hospital, the Carlos J. Finlay Hospital in Havana, was erected in the 1940's and served as the tertiary medical care center for the entire armed forces. A Naval hospital was built in the 1950's. It was operational in the early years of the revolution. The extended health services delivered by the health care military facilities probably covered between active military staff, dependents and retired families approximately 300,000 persons in 1958.
Considering the fact that Cuba's demographic transition occurred in or about 1950 and despite the acceptability of the MMC's, the MC's and the military services, one can estimate the number of Cubans with easy access to health care in 1958 to be of the order of 30% of the population.

Top

Health and Health Care In Cuba:
The Transition from Socialism to the Future.

 The Cuban Health System


Health and health care in Cuba appeared in the proceedings of the jury in which Fidel Castro and his comrades were judged after the violent events that underlined the attack to the Moncada Army Barracks in Santiago de Cuba in 1953. Health and access to health care were listed among Castro's motives for the failed attack and for the nascent revolutionary movement. Although Castro reviewed in his defense in appreciable depth all his stated motives, the number and types of casualties, injured, and dead in the attack, he failed to describe in detail the health measures that the revolutionary government would take to correct the health issues raised earlier. Instead, he gave some specific recommendations on agrarian reform but also fell short of specifics regarding land use, distribution of land, and employment. He concluded with the argument that once the agrarian reform would occur and Cubans were fully and gainfully employed all the other "motivations" for the rebellion would fall into "place," would be corrected, would be taken care of, however.

Since the end of World War II there had been a worldwide movement through which health care was being recognized as a right not a privilege. Inside Cuba, health care was recognized as a right through the revolution but behind the Cuban ideology, there were guidelines, goals, methods and policies provided by the United Nations and its health institution the World Health Organization (WHO). In Cuba, health care during the revolution was organized and controlled by the revolutionary movement and the Communist party. Eventually, all health care was consolidated including all services, workers, providers, and institutions.

At the onset of the Cuban revolution, rapid changes in the provision of medical care both at the individual and community levels were occurring in the world. There were also, in the global arena, important advances in the scientific understanding of various diseases and the emergence of effective pharmacologic treatments of various disorders. These advances were not necessarily part of the Cuban revolution but occurred at a time during which they seemed to be part of the revolutionary process in individual and public health. This process undoubtedly left a mark in Cuban health. Thusly, with the advent of potent drugs to treat tuberculosis, the WHO began to implement in all willing countries methods to control the dreaded infection. Other effective measures advanced the control of poliomyelitis through vaccination. WHO provided thusly the templates, organization and consultations for the control of a number of infectious diseases.

The Cuban health system under the Castro regime has been lauded as one of the major achievements of the revolution. Indeed, the Cuban revolution has attracted appreciable and worldwide attention because of these purported successes in health care access, infant mortality and life expectancy.
Cuban health data and those statistics reported to the international health organizations may be subject to political controls. Although there has been a number of publications (15) on how health statistics are collected, registered, and managed in Cuba, it is important to search for confirmatory data. Such confirmations up to now have been done indirectly by studying related subjects and adjusting Cuban data to parameters verified by independent investigators.

Advances in sanitation were also apparent during the revolution. The provision of clean water to Cubans has not been fully realized, however, in rural areas. Furthermore, with the advent of the "periodo especial" after the collapse of the Soviet block, the status of clean water provision in Cuba became worse. This was evident from the increased prevalence of infectious diarrheal diseases which peaked in 1991 with 10,982 cases per 100,000. (16) The chlorination of water was stopped in some areas during those early and difficult times of the "periodo especial." However, in terms of regional comparisons, Cuba's water and sanitation seems to be equivalent to those of Chile and Costa Rica in the urban setting. In the rural setting, Cuba's data seem better than those reported by Venezuela, a country with a higher per capita income.


Table 3: Comparison of Sewer, Water and Sanitation in Various Countries in the Region, 1998. (17)

Country

 

Water

 

 

 

Sewer

 

  

Total

Urban

Rural

 

Total

Urban

Rural

Chile

94%

99%

66%

  

94%

93%

94%

Costa Rica

95%

99%

91%

 

93%

89%

97%

Cuba

93%

98%

76%

 

94%

97%

84%

Nicaragua

66%

95%

33%

 

76%

93%

56%

Venezuela

83%

84%

70%

 

69%

71%

47%

In 1996, the coverage of liquid waste disposal was 91% for the entire country and 34% of the total population for sewerage services. Collection and final disposal of solid waste has been hampered by transportation and fuel supply problems during the "periodo especial".

Discrepancies between water and sanitation in Havana and rural areas were evident even in 2000. Water may be theoretically available in Havana for 100% and sewage 95% of the population. However, the probability of having water and sewer in some of Granma and the Eastern provinces was 71% in 2000. (18)

In summary, the main areas of advancement where WHO expertise participated were in the fight against tuberculosis, the childhood vaccination campaigns including the fight against poliomyelitis, and the organization of health services to cover all Cubans in all of Cuba. Obviously, the advances promoted by international organizations and the WHO in the delivery of health care provided further strengthening of the high level of control exercised by the central government.

Access to health care.

With the advent of the revolutionary government in 1959 and the entry of the Rebel Army in Havana and other metropolitan areas, the Rebel Army combatants themselves and their relatives began to receive health services in the military hospitals of Cuba. ' Indeed, during the first months of 1959, numerous cases of intestinal parasitism - a disease that was thought mostly eradicated in the urban centers in Cuba - were seen, treated and described in the Carlos J. Finlay Hospital of Havana and other facilities. Very soon, health expeditions were organized in which teams of physicians, nurses, and paramedical personnel traveled to rural areas in order to diagnose, treat and refer patients for medical care. Recognition of the disparities in health and health care between the capital city, other urban sectors and the rural sector became evident.

In the context of all social, political and economic changes (agrarian reform, urban reform, educational reform, etc), the health institutions were also reformed. In 1961, all health and health care institutions were joined together in the MINSAP (Ministry of Public Health). (13) That is, all health facilities were confiscated by the central government. Eventually, over the course of the next decade all facilities were reorganized. By 1969, all health care facilities in Cuba were consolidated under the "Sistema National de Salud." The latter provided a network organized along two main axes: First a horizontal, geographical axis extending from the nation, the province, the municipalities. The second axis was made up of those factors that covered the areas of health care proper: primary care, the specialties and institutes of health. Soon after the onset of revolutionary control, all Cubans theoretically had access to all health care.

Physicians. Nurses and Hospital Beds.

Beginning in 1960, health services in Cuba suffered a human resources crisis. According to official figures, more than 1000 physicians left the country between 1960 and 1964. The vacuum left by these health care workers was filled with medical graduates that were quickly made to undergo a rapid course and training program. By 1964, the number of physicians was returning to baseline. The new physicians pledged through an official oath (19) to be:


• Firstly and foremost Communists,
• To further Communism along with their medical knowledge and skills,
• To renounce to the private practice of medicine, and
• To be like Che Guevara.

The budget for health and health care was also consolidated for the entire country. Initially, in the early 1960's the budget was increased by more than four-fold in amount in when compared to the 1958 health budget to amount (US) $51.3 millions. The MINSAP began thusly as a conglomerate of all formerly governmental facilities, "Casas de Socorros", re-organized private institutions, MMC's, MC's, religious health care facilities, etc. During the time when the former URSS subsided Cuba's economy, the MINSAP's budget increased from 51.3 million pesos in 1960 to 1,015.6 million pesos in 1989. In terms of per-capita expenditures the values were 7.30 pesos per capita (1960) versus 96.66 pesos (1989). In 1989, health accounted for the fourth most important priority with expenditures of 4.3 % of the Gross Domestic Product (GDP). Health was behind education (7.9%), internal security and defense (6.1%), and social security (5.1%). Housing, an important factor in overall health and mental health in particular, was a lower priority with 2.0% of the GDP. Paradoxically, with the advent of "periodo especial" expenditures in health increased. In the PAHO report of 2002, the health expenditures in Cuba went up to 6.8% of the GDP. This amounted to $ 186 per person per year. . By 1999, the MINSAP's annual budget was of the order of 2,728 million dollars. (16, 20)
 

Going back to the early development of the MINSAP, when Jose Marti said that "el que paga ordena" he probably did not have health care in mind. However, MINSAP became the only payer in Cuba's health services and it obviously turned into the only one that "gave the orders." Since the MINSAP was from its inception run by the revolutionaries it follows that it was politicized. Health care in revolutionary Cuba became highly politicized throughout the various phases of the revolution. Physicians and other health care workers truly felt that their political position, ideology and acceptance of the revolution were extremely important and fundamental factors in their professional career and advancement.

MINSAP has claimed that it distributed health care facilities in an egalitarian manner throughout the country. The number of beds in Cuba has stabilized at about 5.1 hospital beds per 1000 population. A comparison with similar statistics in Latin America reveals that Cuba's health services have a higher than average number of beds per capita for the region. The distribution of these hospital beds is not entirely egalitarian throughout the island.

Table 4. Hospital Beds per 1000 population in Cuba. (15, 17)

Country 1964 1974 1996
Chile 4.3 3.6 2.7
Costa Rica 4.5 3.8 1.9
Cuba 5.5 4.2 5.1
Nicaragua 2.3 2.2 1.6
Venezuela 3.3 2.9 3.1

The distribution of beds has not achieved an egalitarian distribution. In the year 2000, Havana had 9.2 beds per 1000 population. However, Sancti-Spíritus, Villa Clara and Guantanamo had 4.0 to 4.9 beds per 1000. Some of these discrepancies may be due to the availability of hospital beds for tourists and highly specialized, tertiary care services such as transplantation in Havana.

According to MINSAP data, in 1980 Cuba's hospitals had an occupancy rate of 80.4% and an average length of stay of 9.2 days. While the number of beds has not changed appreciably (Table 4), the occupancy rate has decreased to 69.4% in 2000. The average length of stay has not decreased as would be expected from better management and utilization. Instead, it increased to 9.4 days per hospitalization.

Cuba has more than fifteen times the number of nurses than Chile but about three fourths of the number in the US. Although Cuba has been criticized for augmenting the number of medical schools to nearly 22, it has achieved a physician to population ratio unrivaled in Latin America.(Table 6 )

Table 5. Nursing Personnel, 1997. (21)

  Country

Rate per 10,000 population

  Chile

4.72

  Costa Rica

10.91

  Cuba

67.76

  Nicaragua

9.19

  United States

97.20

  Venezuela

6.44

 

Table 6. Physicians per 10,000 population in Selected Countries. (22)

Country 1992

1997

Chile 4.1 4.72
Costa Rica 9.46 10.91
Cuba 68.07 67.76
Nicaragua 5.56 9.19
United States 87.78 97.20
Venezuela 7.44 6.44



General Mortality, Infant Mortality and Life Expectancy.

The population of Cuba in 2002 according to PAHO was 11,236,000 inhabitants. The GDP per capita at that time was 2,712. Cuba's population is younger than that of the United States but somewhat older than that of Costa Rica.

Table 7. Structure of Population(%). (23)

Country <15 yrs 15-64 yrs 65-84 yrs

85+ yrs

Chile

27.8%

64.8%

7.4%

0.6%

Costa Rica

31.4%

63.3%

5.3%

0,3%

Cuba

20.0%

69.7%

10.0%

1.0%

Nicaragua

41.9%

55.0%

3.1%

0.1%

United States

21.3%

66.4%

12.2%

1.6%

Venezuela

33.1%

62.3%

4.6%

0.2%

Crude mortality data for Cuba reveal that mortality for the entire population has been increasing steadily. In 2000, Cuba's general mortality was slightly higher than that of the United States.
 

Table 8. Mortality Rates in Selected Countries, (rate per 1000 population). (24)

Country 1993 1998 2003*
Chile

5.5

5.6

5.7

Costa Rica

3.7

3.8

4.0

Cuba

6.9

7.0

7.3
Nicaragua

6.3

5.8

5.3

United States

8.8

8.7

8.7

Venezuela

4.7

4.7

4.7
"Estimated in 1998.

In 1969, the MINSAP recognized that infant mortality was indeed increasing since the 1959, the year when revolutionary government control began. Soon after it was recognized that infant mortality was almost 44 per 1000 life births, approximately 20 % higher than the last data available before the revolution, a national campaign was launched to lower this important health parameter. (25) Now, in terms of public health, infant mortality is recognized to be a valuable and reliable index of four fundamental issues in health care:


1. Access of medical care including maternity and physician services,
2. Education of the population and in particular of the maternal, paternal and family circles.
3. Nutritonal status of the population and in particular of the women of reproductive age and those who are pregnant.
4. Communication and transportation in the community


The MINSAP did not seek to directly improve all of these fundamental areas. Instead, it brought together representatives of MINSAP's Institute of Childhood of Cuba, the Census Bureau, The Federation of Cuban Women (a Communist party mass organization), the Association of Small Farmers (ANAP), and the faculties of pediatrics and anthropology of the University of Havana. In 1969, abortion laws were liberalized in the context of the national campaign to improve infant mortality. By 1972, the infant mortality had dropped to 28 per 1000. Since then, the infant mortality in Cuba has been lauded among the achievements of the revolution. Although a "periodo especial en tiempos de paz" was defined when the Soviet Union and the CAME dissolved, the infant mortality has remained a priority for Cuban health authorities. However, the persistently low infant mortality rates in Cuba in the past 5 years suggest that these data may not be responsive or variable in terms of the usual parameters associated with infant mortality, ie., access, nutrition, etc. Despite the fact that the original campaign to lower infant mortality launched by the MINSAP in 1969 did not attempt to tackle the latter fundamental issues, Cuba has achieved a lower infant mortality as an isolated fact. Therefore, the empirically and sometimes artificially attained favorable rates of infant mortality attest not only to the determination of the MINSAP but also point in the direction where future priorities and goals must be.


Table 9. Infant Mortality in Cuba. (Rate per 1000 live births). (11, 26)

Country

1960

1970

1980

1990

1996

2002

2008*

Chile

109

68

24

14

13.0 

11.6

10.4

Costa Rica 

81

53

19

14

12.4

10.9

9.6

Cuba 

59

38

17

10

8.0

7.3

6.9

Nicaragua

131

98

80

52

41.2

35.7

30.8

USA 

25

18

11

8

7.8

6.8

6.1

Venezuela

73

49

34

23

21.4

18.9

16.7

The most common causes of death in the age group are perinatal complications, congenital anomalies, sepsis, pneumonia, and accidents.

The leading causes of death among children 1 to 4 years of age are: accidents, congenital anomalies, malignant neoplasms, pneumonia, and meningitis.

Table 10. Mortality in Children 1-4 yrs (Rate per 100,000). 1990-1994. (27)

Country

All causes

Infectious Dis.

External Causes

Chile

73.4

16.5

29.6

Costa Rica

60.3

14.3

12.8

Cuba

72.5

16.2

21.6

Nicaragua

730.3

515.8

58.1

United States

49.6

4.1

21.9

Venezuela 

98.8

45.1

23.0

In terms of adults, it is interesting to consider the most common causes of death in Cuba throughout its recent history (Table 11). AT the beginning of the XX Century diarrheal diseases were the number one cause of death. However, since the 1950's. heart disease has been the number one cause of death in Cuba. It is important to recognize the ascending importance of diabetes and accidental deaths, including homicides and suicides. A brief discussion on these current common causes of death follows below.

 

Table 11. First Five Most Common Causes of Death in Cuba in the XX Century. (28)

 

1906

1950

1990 

First Cause of death

Diarrhea

Heart Disease

Heart Disease 

Second 

Tuberculosis

Diarrhea

Cancer

Third 

Heart Disease

Stroke

Stroke

Fourth 

Nephritis

Tuberculosis

Diabetes 

Fifth

Tetanus

Pneumonia

Accidents

In general, life expectancy has been rather stable in Cuba. In terms of comparison, it is evident that the data for Cuba are nearly equivalent to those of other countries of the region such as Costa Rica.

Table 12. Life Expectancy (yrs) (29, 30)
 

 

Total

Men

Female

Country

1998

2002

1998

2002

1998

2002

Chile

75.4

75.6

72.4

73.0

78.4

79.0

Costa Rica

76.9

76.7

74.6

75.0

79.3

79.7

Cuba 

76.1

76.4

74.3

74.8

78.1 

78.7

Nicaragua

68.4

69.11

66.0

67.2

70.8

71.9

USA

76.8

77.5

73.5

74.6

80.2

80.4

Venezuela

72.9

73.3

70.1 

70.9

75.8

76.7

 

Nutriton

In 1962, Cuba began to officially ration food. Claiming that there was malicious speculation in the market due to the limited availability of food products and the increasing purchasing power of the population, the revolutionary government organized and distributed a rationing system. A ration card was used to keep records of the allotment of foods and other goods allowed and dispensed to the entire population. In the early 1980's food rationing was still practiced and included, nominally, the following products:

Table 13. Cuban "libreta" circa 1985. (31)
 

Food Item

Per Capita Quantity per month

Rice

5 lbs

Beans

20 ounces 

Oil

8 ounces  

Sugar

4 lbs

Milk

3 cans

Coffee

4 ounces

Beef

1  1/4 Ibs

Chicken

1 11/16 Ibs 

Bread

15 lbs

Potato

6 lbs

Oranges

1 lbs

Tomato

3 lbs

The availability and distribution of these products was seldom efficient and complete according to the "libreta"( a systematic ration book for foods and certain other products introduced in 1962). Not infrequently, there would be variations in the amounts and delays in the arrival of quotas to the local stores. For example, rice would be available but two pounds would be delivered instead of five pounds. At times, bread was available in the prescribed quantity but only one out of four days. Other products were available only to special populations. For example, fresh or reconstituted powdered milk was available only to children under the age of seven. Some items such as oranges were seldom available except through a medical certificate or when shipments to foreign countries had been cancelled. For example, at one point in the mid 1960's oranges became available in the Vedado neighborhood of Havana. One attentive merchant noticed that the boxes displayed signs stating: "excedent revolution cubaine pour le peupple de l' Alegrie." Obviously, it is not difficult to conclude that the nutrition of Cubans was less of a priority those the foreign relations of the Castro regime with the North African country. Since health had been politicized, it is not surprising that one important aspect of health, nutrition, would also fall in the same disgrace.

It should be pointed out here, that nutrition experts have been very cautious in their dietary recommendation after the discovery of the water soluble vitamins in the XX Century. Invariably, it is generally agreed that the human diet needs to be varied, Cuba has enacted since the early sixties a systematic control of the Cuban diet. It should not be surprising that a large segment of the population have been under a fairly egalitarian regimen of nutrition for more than 40 years. The nutritional catastrophe did not occur until the "periodo especial" with the onset of the optic neuritis and neuropathy epidemics of the early nineties immediately after the dissolution of the Soviet Union and the disbandment of the Socialist Council of Mutual Economic Assistance (CMEA; Consejo de Ayuda Mutua Economica, CAME). Cuba's market in CMEA consisted mainly of bartering sugar, nickel, oranges, other citrus products, and raw materials in exchange for food, petroleum, industrial products, machinery, etc.

The nutritional catastrophe was not the only area of health that became critical after 1989 when the Soviet block collapsed. (32) The health budget for Cuba's health expenditures had increased to more than twenty-fold the level of expenditures in 1960 amounting to nearly 1.2 billion dollars annually. The crisis became known throughout the world. By 1992, a MINSAP vice-minister was describing at the WHO in Geneva the clinical aspects of a mysterious epidemic involving amblyopia, loss of vision, and neuropathy. This was not only a medical and epidemiologic crisis. It was also - since health care and administration were politicized - a political crisis where some leaders in the MINSAP became marginated because their position vis-a-vis the optic neuritis epidemic and their explanations and understanding of the epidemic was not entirely "correct" according to the official points of view. The latter included an apparent strategy implicating in the epidemic a number of etiologies that eventually lead to the financial contributions of several countries and the WHO to the Castro regime of more than 18 million dollars for the assessment and control of the epidemic. Some of the presumed etiologies for the epidemic that Cuban officials attempted to suggest and propagate were: incrimination of an unknown agent, a toxic agent from soy products or other factors in the environment, tobacco viruses or toxins, blame for the epidemic on the American economic embargo to the Castro regimen, and the possibility of a new disease from a known virus. The epidemic affected more than 50,000 Cubans in the early nineties. It began to abate through nutritional supplementation and management, the use of vitamin supplements particularly vitamin B-12, and the provision of protein and amino acids of nutritional adequacy.

Since 1993 there has been a slow but documented improvement in the nutritional intake of Cubans. According to official data, the average caloric intake increased from 1993 to 1997 from 1863 kcal/day/person representing 76% of estimated requirements for the entire population, to 2176 kcal/day/person. The latter figure is still below the WHO recommendations by 9.4%. Given the medical significance of these global data calculated from total amount of food available to the population divided over the population, it is obvious that deficiencies in both major and minor nutrients are likely in Cuba.

Iron deficiency anemia is the most common nutritional and metabolic disorder in Cuba. More than twenty percent of pregnant women are affected by iron deficiency in the third trimester of pregnancy. These complications of pregnancy are associated with low oxygen delivery to the placenta, complications of the puerparium., infection, and iron deicienfy in the neonates. A nutritional study carried out in 1999 in Havana revealed that 46% of children 6 months to 2 years of age were iron deficient.

Table 14. Anemia in Pregnancy, 1993. (33)

Country

Percent Anemic

Chile

1-2%  

Cuba

25-35%

Common Morbidities and Specific Disease Categories,

According to data submitted to PAHO, the main causes of death in Cuba are: heart disease, stroke and circulatory problems, cancer, and external causes (see below under mental illness) .

Table 15: Leading Causes of Death in Cuba 1996-2000. (34)
 

Causes of Death

Mortality Crude Rates per 100,000 pop.

1996

1998

2000

Cardiovascular Diseases (ICD-9, 383-429)  

206.3

193.2

180.3

Malignant Neoplasms(ICD-9, 140-208)       

137.4

147.4

146.5

Cerebrovascular diseases(ICD-9,430-438)   

72.2

74.9

72.9

Influenza and pneumonia(ICD-9,480-487)  

40.4

47.3

44.5

Accidents (ICD-9, E800-E949)                   

51.6

46.9

44.5

Circulatory diseases of arteries (440-448)    

31.9

33.7

32.6

Suicide and self inflected injuries (E-950-959)

18.3

18.4

16.4

Diabetes mellitus (250)                               

23.5

14.3

13.1

Chronic liver disease (571)                         

8.4

10.1

8.9

Homicide (E-960-969)                                

6.6

5.5

5.3

Cardiovascular Diseases

Diseases of the heart have been the most common cause of death in Cuba for more than 40 years. The leading disorder is coronary artery disease. It should be noted that although Cuban health services have an organized national health system that should be able to handle anything from a puncture wound to a liver transplant, it is difficult to find Cubans who have been intervened through coronary artery bypass surgery. The lack of surgical treatment of this deadly illness may be the result of idiolegical issues. Socialistic medicine has been known to favor prevention rather than curative or surgical treatments. In the setting of the transition, however, it seems appropriate to evaluate the preparedness, skills, and outcomes from this type of intervention in Cuba.

Hypertension is common in Cuba. Although in the 1970's and eighties the prevalence of high blood pressure was of the order of 15 to 20% of the adult population older than 15 years of age, the prevalence has increased in 2000 to 30 according to PAHO data. In fact, the rate of hypertension is increasing and death from hypertension has been increasing. Official data from MTNSAP published by PAHO reveals that the risk of dying from high blood pressure in Cuba increased from 8.9% in 1996 to 11.5% in 2000 in both men and women. In the transition, it is important to organize a systematic detection of hypertensives with appropriate guidelines and methods in order to begin treatment this disorder in order to prevent end organ damage and premature death from cerebral, vascular, cardiac, or renal complications.

 

Top

Malignant Neoplasms

Cancer has been a leading cause of death in Cuba for the past 30 years. From 1985 tp 1993, the most common cancers were:

In men: lung, prostate, skin, bladder, and colon.
In women: breast, skin, lung, and colon.

There has been a moderate degree of compliance in the directives of the national campaign on preventive measures. The backbone of Cuba prevention centers in PAP smears, and self-examination. Official data suggest that in women older than 30 years of age, only 26% performed a self-breast examination in the 12 months prior to the study.

Another illness that is increasing in prevalence in Cuba is cancer. Some common cancers are cancer of the trachea, bronchus, and lung. These account for 22% of all cancers in Cuba. In 1997, breast, lung, skin, cervix of the uterus, and colon accounted for 50% of all cancers.

Diabetes Mellitus

Diabetes is the eight leading cause of death in Cuba in 2000. The reported mortality from diabetes was 23 per 100,000 in 1996 and 13 per 100,000 in 2000. The prevalence of the disease is increasing, however. The prevalence of diabetes in 2000 was 23 per 1000 population, that is almost 3 % of the entire population. The decrease in the mortality from diabetes in the past 8 years has been attributed to better identification of cases, improved availability of effective medications to treat diabetes and diabetic complications, and improved training in medical schools and hospitals concerning this prevalent disorder. Cuba has been importing insulin products from Mexico for a number of years. However, most diabetics reported in a nutrition and health study carried out in 1980 were controlled on first generation oral agents and diet therapy.


Infectious Diseases

The usual infectious diseases of the Third World countries of Latin America, parasitism, enteric diarrheas, etc have been either eradicated or highly diminished in Cuba. There is still, however, an ongoing endemic of giardiasis. The incidence of instestinal infections in 2000 was 77.1 per 1000 population, a rate that is not negligible. However, the latter was 25.7% lower than the similar rate in 1994. Obviously, there seems to be a tendency towards improvement.

Tuberculosis control in Cuba was traditionally based on isolation techniques until 1926 when the first campaigns were launches with BCG vaccination. In 1936, the National League Against Tuberculosis Infection was organized and tuberculosis hospitals were planned, built and equipped. With the advent of effective chemotherapy against the tubercle bacillus through the antibiotic isoniazide, the prevalence of tuberculsosi decreased. Infection with the tubercle bacillus, however, increased in Cuba in the 1990's. It is possible that this trend in tuberculosis cases was multifactiorial in terms of the crisis brough about by the "periodo especial", the rising prevalence of HIV/AIDS cases, and the increasing contacts with foreigners through tourism. Recent official data suggest that the tuberculosis epidemic is abating. In terms of regional comparisons, Cuba seems to have less tuberculosis than Nicaragua but nearly four times more than Costa Rica.

Table 16: Tbc Incidence (Rate per 10,000 population) (35)
 

Country

1994

1995

1996

Chile 

30.2

28.0

25.7

Costa Rica

9.8

8.9

4.1

Cuba

15.6

14.4

14.0

Nicaragua 

70.7

63.7

59.4

United States

9.3 

8.4

7.5

Venezuela

23.3

23.7

21.9

The incidence of venereal diseases reached serious epidemic proportions in Cuba during the revolution. The incidence of some diseases such as gonorrhea increased to 500%. Cuba has been reported to be an exporter or such exotic diseases as Norwegian scabies. The prevalence of HIV/AIDS has been increasing slowely despite purported measures to fully control this ailment. Cuba's AIDS campaign to control this pandemic disease was begun in 1986 when the epidemic was already prevalent in the island. Since 1983, however, Cuba ha stopped the importation of blood and blood products into Cuba from countries known to have HTV7AIDS although at the time the HIV virus was not identified, isolated or incriminated as the etiologic agent of HIV/AIDS. According to official data reported by PAHO, Cuba has identified 3,231 cases of HIV infection by 2000. Of these, 1,194 had devolped  AIDs and 840 had died. The increase in HIV/AIDS incidence has been notable. The reported rate of these illnesses was 8.9 per million population in 1996 and 15.1 per million in 2000. Most cases, 98%, are the result of sexual transmission. The most common risk factor is the presence of venereal disease. The rate of gonorrhea is 170 cases per 100,000 population in 2000. The rates for syphilis were high in 1997 when the cipher reached 143 cases per 100,000.

However, it must be said that HIV/AIDS data in Cuba are considered a state secret. The reported cases of HIV/AIDS has never been documented by independent observers. Given the deadly nature, epidemiologic, medical and financial importance of HIV infection, it is imperative to plan for an epidemiologic study in the transition period.

Hepatitis B has been under systematic surveillance since 1987. Since 1992 a universal campaign whereby all newboms are vaccinated gainst hepatitis B is under way. A campaign to test all blood donations for hepatitis C has begun since 1995.

Dengue has been endemic in Cuba for the past centuries. This is a viral illness similar to yellow fever that is amenable to epidemiologic control through the control of its vector, the Aedes aegypti mosquito. Bouts of dengue fever had not been rare in the first half of the XX Century. Severe dengue or hemorrhagic dengue, however, has not been seen in Cuba or the Americas until the late 1970's. Although Cuba became a significant source of migrations to Africa, Latin America and other regions since 1962. These migrations eventually led to massive involvement in what was termed "internationalistic duty". Eventually, by the 1980's Cubans had migrated to all continents and the Castro regime had brought foreigners from all continents to the island for educational and military training. The resultant demographic exchange involved at one point in time more than 500,000 Cubans in Southern Africa and Angola. These massive migrations led to a number of changes in the diseases commonly observed in the island. At this climax of these migrations, a complicated form of dengue fever, Dengue Hemorrhagic Fever (DHF), was diagnosed first in the Western Hemisphere. DHF is a complicated form of dengue that not infrequently results in death despite appropriate medical care and rapid recognition.

Dengue was diagnosed in Cuba in 1981 when 344,203 cases were diagnosed. DHF was diagnosed in 10,312 cases and 158 patients died. Since then, DHF has been diagnosed in 25 countries in the Americas resulting in 42,246 cases, and 582 deaths. In 1997, Cuba experienced another dengue epidemic. The management of the dengue epidemic was politicized and it has not been clear to this date what led the authorities to apprehend and later expel from the country a physician, Dr. Desi Rivero Mendoza, who informed the media about the epidemic in the Santiago de Cuba health sector.

The incidence of meningitis secondary to pneumonocci increased in 2000. Cuba has had a number of epidemics of meningitis in the past 5 years. Various types. A, B, and C of neisseria have been reported. There was also an epidemic of viral meningitis secondary to echovirus 16.

Top

 

Respiratory Illnesses

Asthma is a common disease in Cuba. The rate of asthma increased according to PAHO from 5.9% in 1996 to 7.7% in 2000. There has been an association between the increasing prevalence of asthma and the increasing rates of tobacco use and the use of kerosene for alternative fuel in the home for cooking. The current prevalence of tobacco use is officially 36% but estimated to be higher than 50%. Although it has been stated by PAHO and some agencies that air pollution is not a serious problem in Cuba,, it. is possible that air pollution may be a confounding problem in the context of increasing dependence on crude oil use with high sulfur content in the increasing prevalent of asthma. Other respiratory ailments are also common including respiratory infections. Vaccination against pneumococcal pneumonia and influenza are not carried out for the usual risk groups in Cuba. Only in 1997, was a limited vaccination campaign against influenza carried out through vaccination of the elderly admitted in nursing homes and "casas de abuelos." Respiratory infections account for 30% of hospital admissions in Cuba. The number of outpatient visits in health care facilities is, according to data from PAHO. more than 4 million annually.

 

Table 17. Recent data on Cigarette Smoking in Selected Countries. (36)
 

Country (Year)

Men (%)

Women (%)

Chile (1990 

37.9

25.0

Costa Rica (1988)

35.0

20.0

Cuba (1990)

49.3

24.5

United States (1993)

27.7

27.5

The prevalence of asthma is increasing in Cuba. It increased to 7.7% of the population in the year 2000. Major problems have been reported from Cuba in the management of asthma. The use of kerosene for home cooking has been well documented to be an important trigger for the development and worsening of asthma.

Women's Health

Family planning has been available in Cuba since 1966. According to official figures, Cuba's fertility rate is the lowest in Latin America. Contraception is carried through standard medical measures such as hormone treatments )oral contraceptives), the use of intrauterine devices, and the widespread use of abortion. Initially in the revolutionary period, lUD's were manufactured in Cuba from nylon suture material. Later, copper containing devices were used. It is estimated that Cuban women of reproductive age have had had an average of 0.4  , abortions per life birth in 1972 according to official data. The rate of abortion is highest in Havana where the rate is nearly 1.0 abortion per life birth. Interestingly, it was in Havana where the Cuban physician, prisoner of conscience, Dr Oscar E. Biscet Gonzalez first proclaimed his dissident point of view against abortion. Bisect and Rivero Mendoza are not the only physicians who have been literally cought in political crossfire in Cuba. Earlier, Dr. Omar del Pozo Marrero was' apprehended in the context of a letter he wrote to the head of the MESfSAP arquing in favor of human immunodeficiency virus infected patients, their treatments, their rights, and the overall management of the HTV-AIDS epidemic in Cuba.

In 1990, the average number of pregnancies per woman was 3,04. The rate of abortions per life births was 1.0 and therefore, the rate of abortions per woman was also 3.04.

High rates of abortion are known to be associated with social, biological, and economic factors. Among these factors are: low fertility, marriage status, contraception use, knowledge and acceptance, and infecundability after illness or childbirth. The latter may be a factor in Cuba since the prevalence of venereal diseases has been documented to be high since the seventies. All of these data suggest that there has been a suboptimal education for women of reproductive age on contraception and parenting. The methods of contraception reported in Cuba are summarized in the table.

Table 18. Methods of Contraception in Cuba, 1990. (37)
 

Method

Percent Use

Intrauterine device

74%

Oral contraceptive 

51%

Condon

6%

Diaphragm

3%

Periodic Abstinence

2%

Lactation

2%

                * More than one women may have used more than one mthod of contraception.

These data clearly point at the fact that Cuban health authorities have recognized that abortion is being abused and used at times as a method of contraception.

Cuba has a clear advantage in the rates of vaccination since levels of 100% have been reported for the past 20 years while in some Latin American countries vaccination rates are less than half of the population at risk. This is true for both boys and girls.

Table 19. Vaccination Effectiveness, 1996. (38)

Country

Health Districts(n)

% Persons Vaccinated 

Chile

336

77

Costa Rica

81

69

Cuba

169

100

Nicaragua

152

80

Venezuela 

597

49

While it is definitively laudable for a health service to be able to accomplish the vaccination of 100 % of a population at risk, one could ask, about the prevention of other preventable disease for girls. One such disease that is nearly 100% preventable is carcinoma of the uterine cervix. This is a currently a preventable disease through the systematic use of cervical smears to detect signs of neoplasia or preneoplasia. Cuban women are indeed very conscientious of their "Pappanicolau status."

If one looks at the effectiveness of the MINSAP in terms of preventing carcinoma of the cervix, it may proof valuable to compare the Cuban data versus the US data. In the US, there are more than 40 million persons (approximately 15% of the population) without health insurance and presumably not able to have timely access to a "Pappanicolau" test for early detection of cervical carcinoma.

The mortality from carcinoma of the cervix in the US is 3.1 per 100,000 population while the corresponding parameter for Cuba is nearly doubled, 6.1. Therefore, it is not clear or evident that reasonable extrapolations may be safely and reliably made with regards to the Cuban Health Service. One would have predicted in the case of carcinoma of the cervix, that the Cuban rate would have been much better than that of the US.

In terms of the future, however, a malignant disease of women has turned in the past decade through medical advances achieved outside of Cuba, into a disease preventable through! vaccination. In the future, carcinoma of the uterine cervix associated with infection with human papilloma virus type-16 may be prevented through effective vaccination.

Top

Dental and Oral Health

Dental health is a function of a number of genetic, environmental, nutritional, and health care factors.

The policies and practices of fluoridation in Cuba have not been well documented. In the transition, it is important to consider this effective measure when the water services are reviewed. In most countries of the region, however, the limiting factor in dental health is not fluoridation but access to dentists and dental clinics.

 

The dental health of Cubans was not optimal in 1980 according to a study performed on newly arrived refugees. At that time, the dental health of Cubans was similar to that of the poorest Americans in the Ten State Nutrition Survey. However, the most recent data from PAHO attest to the fact that some aspects of dental health have improved in Cuba. (Tables 20 and 21)

There has been a marked decrease in the index for missing and carious teeth in Cuban children. Cuba has a greater number of dentists when expressed in terms of the population than all countries in the region. This may present a financial problem during the transition. Again, as discussed for physicians above, it may be necessary to diversify the responsibilities of dentists, provide service or training in sub-specialties abroad, or retrain willing dentists into other, akin professions or occupations in higher demand^ Obviously, the number of dentists like the number of physicians that a health society can afford will depend on the individual and national priorities, the economy and the regulatory issues that may legislated and enforced.

Table 20. Dental Health in Cuba (Dentists per 10,000 pop). (39)

Country

1992

1997
Chile

3.82

4.15
Costa Rica

3.76

3.94
Cuba

7.45

8.45
Nicaragua

1.24

1.86
United States

6.26

5.98
Venezuela

3.94

5.71

 

Table 21, Dental Health (DMFT) In Selected Countries.(40,41)
 

Country

1990

2000

 

 

 

Chile

4.1

3.1

Costa Rica

4.9

2.5

Cuba

2.9

0.8

Nicaragua

3.7

NA

United States

1.4

NA

Venezuela 

3.9*

2.5

* data for 1987

Oral cancers are not uncommon in Cuba. The incidence of cancer of the lips, oral cavity, and pharynx has been of the order of 4 to 5 per 100,000 population at the end of the past decade. Factors that are known to be involved in the development and progression of these cancers are tobacco smoking and alcohol use. It is estimated that 80 percent of adult Cubans use both of these products regularly.

 

Top

Mental Illness, Suicide, and Violence.

Finally, one area that has received loud support in Cuba has been the management of psychiatric illnesses during the revolution. The "Hospital Siquiatrico de La Habana" in the outskirts of Havana at Mazorra was improved and a number of apparently novel psychiatric regimens used. The advancements of psychopharmacology in the past fifty years, however, has been of great importance in terms of the medical management of diseases of the nervous system and behavior. Cuban psychiatric practice had not been free from criticism, however, in terms of its misuses for political or personal reasons. One area seems clearly important in the area of mental health. It is an area where there is a consensus between those who see the MINSAP's psychiatric services are loudable versus those who do not. It is in the area of suicide and violent deaths.

The fourth leading cause of death in Cuba is "external causes." That is, homicide, suicide and violent events. Cuba has an inordinately high rate of suicides compared to other countries with similar cultural backgrounds in the Caribbean region. In 1998, the MINSAP reported to WHO that the rate per 100,000 population of suicide in Cuba was 25.4 in men and 15.3 in women. The overall rate of external causes ( accients, suicides, and homicides) was 79 per 100,000. The corresponding averages for all countries in the Americas are: 13.8 in men and 3,3 in women. The overall suicide rate in Cuba for both men and women is 20.4 per 100,000. This figure is nearly four-fold greater than the average for the region. Data from PAHO has suggested that the incidence of suicide in Cuba has decreased somewhat to 16 to 18 per 100,000.

In the context of mental illness it seems appropriate to consider the high rates of alcohol consumption in Cuba. It is estimated that 80% of the adult population in Cuba consumed alcohol regularly on a daily basis or consumes alcohol in binges until the supply available runs out.

Another area of mental health that seems to be deteriorating steadily is the area of the prevalence of post-traumatic stress disorder, dementia and cognitive impairment. According to a 2000 study from PAHO, 4.38% of Cuba's population in the age bracket of 60 to 74 years of age suffered from dementia of the Alzheimer's type. The prevalence of this serious illness increased in Cuba to 22.87% of the population 75 years old or higher.

Top



Biotechnology

The island has been involved in biotechnology since the early 1980's. Cuba's biotechnological initial investments have been estimated at approximately 800 million dollars. It has been noted, however, the expected monetary return from these investments has not been realized. However, the facilities have been claimed to be state of the art in terms of vaccine manufacturing and other biotechnological techniques. A much-propagandized vaccine against meningococcal disease type B has obtained mixed reviews in the medical literature. However, an Euro-American pharmaceutical giant purchased rights to investigate the product several years ago but results of their research and development on the meningitis B Cuban vaccine have been lacking thus far.

Despite the magnitude of the investments, Cuba does not seem to be the leader in Latin America with regards to vaccine production. Current information from PAHO summarized in the following tables does not suggest that Cuba has gained a preeminent position on biotechnology in the region.

Table 22. Vaccine Production Facilities in Latin America, 1998. (42)

Country 

Number of facilities
Brazil 5
Argentina 3
Cuba  2
Mexico 2
Chile 1
Venezuela  1

 

Top

 

Health and Health Care In Cuba:
The Transition from Socialism to the Future.

Health Care Priorities In the Transition.
 

Health must be considered a high priority during the transition. Whatever political and logistical priorities become evident during the transition, issues regarding health and health care must be prioritized in order to gain the trust of the people and reassurances that this right will surpass any political and economic change. The experience gathered during the rafters crisis in the Guantanamo Naval Base camps suggests that the vast majority of Cubans will support hardship and inconveniences provided that certain important goals, including health care, are defined and appear tenable.

The priorities in terms of health care during the transition can be grouped as follows:

  1. Harnessing popular support, providing fundamentals of hygiene, water, etc.

  2. Depolitization of the MINSAP and all health services,

  3. Surveying health status and health services and educational resources,

  4. Providing reasonable health goals for all.

  5. Maintaining and possibly expanding international cooperation with individual countries and regions and the WHO.

Initial surveys and provision of a safety net in health and nutrition.

It is imperative to evaluate the MISAP health data in order to verify any irregularities in the collection or management of epidemiologic data, mortality, inventories, etc. If there are recognized political priorities and controls in the MINSAP data collections operations, these must be evaluated openly and depoliticized. The execution of a limited but national health survey seems important in order to understand current published heath statistics and be able to plan for future use of resources during and after the transition. Together with these evaluative measures, it is imperative to work on water supply and housing so that the provision of health services can be optimal.

Emergency services and rescue services must be organized throughout the island. This seems appropriate in order to be able to treat emergencies such as trauma, myocardial infarction, etc. It is also important in terms of demonstrating to both the population and the health professionals that there is a clear determination in the part of the transition leaders to maintain and improve health and health care in Cuba.

It is also necessary to provide appropriate nutrition to the population at large. Although the "libreta de racionamiento" has not had the best of reputations in revolutionary Cuba, an effective, reliable nutritional safety net tool should be made available to the Cuban people during the transition. Such tool may begin, for example, with the provision of free food, going to highly subsidized foods, and later as the economy develops perhaps it will be appropriate to consider food coupons or the like. This scheme is equivalent to a welfare type of program. Again, this safety net should be available to all Cubans for a limited period of time while the entire economy and the country goes through the transition into a viable society. The tool for the nutritional safety net may be called "Plan Asistencia Temporal" It may be considered to provide a food safety network providing at least 2,000 calories per person and 60 gram of protein. The items in such nutrition service may vary, but they must be culturally acceptable for the Cuban population. This last "libreta de racionamiento" must be understood to be a safety net that will be tapered off during the next three years. An alternative to this type of safety net is the provision of food coupons or globally subsidized prices. Obviously, the timing for the evolution of the safety net may be flexible and can be adjusted depending on the availability of resources, the popular response, overall improvements in the available resources, the economy, etc.

Organization of health services

The focus on health and health care during the transition must center initially in those areas that are known to be suboptimal. Some of the ills of the Cuban health services have indeed persisted throughout the period of time when the subsidies from the former USSR were the mainstay of the MINSAP's budget. It is worthwhile to look further into the assessment performed in 1982 by the Joint Economic Committee of the United States Congress. (9) The latter stated that not withstanding the 13 billion dollars of Soviet aid, Cuba's performance could be cited on these failures:

a)  Dependence on massive infusions of external aid.

b)  Real economic growth has barely exceeded population growth.

c)  Stagnant living standards.

d)  The existence of an oppressively inefficient bureaucracy.

e)  Poor labor productivity.

f)   Predominant and excessively centralized management.

Therefore, initially, it seems appropriate to depoliticize the MINSAP. This may be quicker said than done, however. An integral program of health services may include some or all of these initiatives.

1. Defining local health councils made up of physicians, health care workers, administrators, and individuals representing the local government.


1a. Empowering these health councils to serve as the communicators and regulatory agencies for their municipality or district.

1b. Each of these health councils must have access to the radio and the media in order to give directives on services available, open discussions on health issues, and entering into a dialog between all parties involved.

1c, The local health council will be responsive to local issues.

 

1d. The local health council must serve implement the guidelines, ethics, practices recommended from the health councils in the province and the nation.

2. Defining a health council for each province and for the nation.

2a. Representation of health councils from the municipalities in the provincial health councils.

2b. Representation of the provincial health councils at the national level.

2c.Establishing norms and guidelines for financial organization of the health system, developmentof a national budget, and providing leadership in services to be marketed abroad.

3. Physicians and health care workers serving in these committees must be elected by the health care work force and the electorate.

These entities will tend to decentralized the MTNSAP. The health councils must eventually establish the priorities for health care in the entire country. Legislation must obviously be enacted through the transitional government and beyond since the current legislation may be obsolete or lacking. In fact, the WHO resources do not have active data on Cuba's health legislation.

A priority is obviously the development of a working budget. The current budget seems high, but the expenses may indeed by even higher during the transition in order to correct fundamental deficiencies such as physician and health care workers salaries, repairs of infrastructure, and improvement in water supply, housing, and transportation of the ill.

Independent organization should be stimulated to group and represent physicians, nurses, technicians and other health care workers. These organizations would be active players in the support of the health councils. The future role of these entities must be dealt with at the level of regulatory commissions in the legislature and government.

Physicians and health care workers.

Given the strong political control of physicians and health care workers for more than four decades, it seems important to consider de-indoctrination of these workers early in the transition. Since physicians have been subjected to a "Communist medical oath", it seems appropriate to develop a non political oath for them. Physicians must specifically be submitted to a thorough process of de-indoctrination regarding the role of their profession in an open, multifaceted society. This process may be discussed and researched prior to the transition and organized so that definition of ethical and professional priorities may be defined before the actual transition. Obviously, these preparations for the transition may be hampered by the lack of free communication between physicians and their groups in the island in the actual regime.


One area that has received criticism during the revolution is the number of physicians active in Cuba. The US, however, has a greater number of physicians when the number is expressed in terms of its ratio to population. The number of physicians in Cuba may be indeed excessive for the demands during the transition and the financial support of the economy, however. Cuban physicians are not diversified along all possible lines of specialization in the medical profession. Indeed, there are medical specialties in North America and the Caribbean that have not been implemented in Socialist Cuba and may be used in the future to improve:

a. Patient care and access.

b. The utilization of existing physicians during the transition and thereafter.

For example, although diabetes is a rather common disease in Cuba affecting from 5 to 10 percent of the population, Cuba does not have community based podiatrists or diabetes specialists to assist in the diagnosis and care of these patients. These specialists may be developed to provide much needed care at the level of the "policlinicos."

Another area where physician diversification may aid in the provision of health care during the transition is in the area of emergency medicine and rescue. Although Cuba has acquired an extensive experience in military medicine during the revolution, the transposition of those skills to the care of civilians in terms of trauma, management of myocardial infarction, psychiatric emergencies, hypertensive emergencies and other emergencies has not occurred. The lack of emergency services in the community throughout most of the revolutionary period may indeed have been related to scarce resources during the "periodo especial." However, ideological issues may have ruled against the establishment of such services during the hey day of soviet financial assistance invoking that socialistic medicine had to prioritize prevention at the expense of care for emergencies that could have been - at least theoretically - prevented.

One last area of consideration in terms of physician diversification in the setting of the proposed depolitization of MINSAP is the consideration for the expansion of services in foreign countries for Cuban physicians for both training and service missions. Cuba has participated through a number of agreements with foreign countries where the island's MINSAP has provided physicians and health care workers for service in South Africa, Zimbabwe, and many other countries. All of these covenants up to now have been subject to political review and compliance in Cuba. The financial benefits generated through these agreements have gone in great measure to the MINSAP and the Cuban government, not to the physicians participating in the exchanges. During the transition, it may be appropriate to consider expanding these exchanges without ties to political issues while providing a greater part of the financial benefits to the participants in the program and not to the MINSAP or the equivalent governmental organization.


The evaluation and care available for common diseases such as cardiovascular, stroke, hyperetension, and diabetes must be considered, reviewed, and discussed. Special problems of pediatrics and geriatrics must be defined and resolved within the available resources. The area of mental health needs special attention during the transition period, however. Classically, the number of suicides have increased in times of distress. Therefore, it is not unreasonable to think that the prevalence of suicide is liable to increase during the transition period. Proper planning for counseling services and early detection of those prone to suicide should be considered in the health planning for this process. Open access to professional health advise on the radio seems appropriate for the transition period.

Biotechnology

It is important to recognize, however, that the investments made in the biotechnology industry in Cuba should not be wasted and could be channeled in a manner that will be useful to both Cubans and humanity. In the past two years, a multinational pharmaceutical company has contracted with the Cuban government to study one of Cuba's most boasted products, the neisseria meningitidis type B vaccine. This vaccine has\been used in Cuba and several countries with ties to Cuba with variable, somewhat suboptimal response. There is a need, however, to de-politicize the biotechnology industry in Cuba in order to allow it develop, within the appropriate regulatory frameworks dictated by the national and international community, to its highest levels of achievement in production, and research and development.

Furthermore, in the rapidly evolving world of biotechnology, it is important to realize that ideology and infrastructure provide only partial support for the multiple requirements demanded by the global economy. In terms of the immediate future of Cuba's biotechnology investments, it seems appropriate to consider the globalization of the markets, the distribution networks, the various patents and regulatory agencies in the regions and countries where the products of such a commercial venture will be sold, and the logistics of marketing in a global commerce. Despite these facts, it will be important to use the Cuban biotechnologic investments in the area of medical research through state institutes and institutions of higher learning. Socialist Cuba in transition towards an open society in a market economy, can consider the entry into leasing and/or joint ventures with global pharmaceutical and biotechnologic companies in order to quickly have an income and an impact in the markets arising from these vast investments that up to this time have not yielded their expected fruits.

Conclussion
 The organization of health services and special attention to physician and health care worker status need attention during the transition. A general health and nutrition survey is recommended in order to define the health status of the Cuban population and reassure them that health is a most important priority in the future of Cuba.     As Cuba embarked in the 44th year of monopartisan, totalitarian socialism (Communism), the health and health services in the island were in a difficult process of adaptation and survival. Attempts to the strengthen the Cuban civil society, reform of the State into a pluralistic more truly transparent and participative style of government, have encountered failure at every turn associated with manipulation from internal governmental forces and silence or empty promises from the international community, the media, and various organizations such as The Carter Center. The persistence of the myth around Cuba's health services has helped to justify the agenda of the current political regime. However, the myth also serves to provide a goal for those who will carry the torch of health services once the current regime passes.

The future evolution and maintenance of expectations in the health sector in Cuba require ethical, organizational, regulatory, and financial review and planning in order to meet the national and international expectations on health parameters and health care. In a more open society, it is also important to be able to meet the national needs of the people throughout the entire island. The assessment of health and health care needs must take into account the needs of the people as consumers of health services and also the needs and expectations of health care providers (physicians, nurses, technicians, paramedical personnel, etc) in order to optimize resources and outcomes. It is imperative to be able to harness all available resources, human and otherwise, to carry out these health care plans while avoiding exhaustion, underemployment, and burnout of the fundamental resources, the human ones.

Top

 

Notes and References

1.  Marrero, L. Cuba: Economia y Sociedad. Vol 1. Madrid. Playor. 1978.

2.  Chocano, G., Fernandez Vial, I, Varela, C. La Santa Maria, La Pinta y La Nina. Sociedad Estatal Quinto Centenario. 1991. Madrid.

3.  Thomas, H. Cuba, or, The Pursuit of freedom. New York. Plenum. 1998.

4.  Finlay, C.J. Real Academia de Ciencias de La Habana, 1881.

5.  http ://hsc.Virginia, edu/hs-library/historical/yelfev/tabcon.html Accessed May 4, 2003.

6.  Finlay, C.J. Yellow Fever: Historical Sketch of the Disease, its Etiology and Mode of Propagation. In Carlos J. Finlay Obras Completas, Habana. Pp 265-292.

7.  Le Roy, J. La Salud Publica en Cuba. 1920.

8.  Gwatlin, D.R. and Brandel, S.K. Life Expectancy and Population Growth in the Third World. Scientific American. Vol. 246. pp 57-67, 1982.

9.  Joint Economic Committee, Congress of the U. S> "Cuba Faces the Economic Realities of the 1980's " U.S. Government Printing Office, Wash.* D.C. (91-4120) 1982.

10. Period of the revolution after the collapse of the Soviet block when Cuba lost a significant number of its trading partners and subsidies.

11. Hernandez, R.E. "La Atencion Medica en Cuba Hasta 1958." Journal of Inter-American Studies. Vol XI, No. 4. pp533-557. 1969.

12. Basch, P.F. International Health. New York, Oxford Univ. Press. 1978. Page287.

13. Danielson, RS. Cuban Medicine. New Brunswick, N.J. Transaction Books. 1979.

14. Diaz-Briquets, S. The Health Revolution in Cuba. Austin, Univ. of Texas Press. 1983.

15. Rios Massabot, R.E. Sistema de information de estadisticas vitals en Cuba. Rev. Cub. Adm. Sld. Vol 9, p 16-25. 1983.

16. Ministerio de Salud Publica (MINSAP) 1999. "La Salud Publica en Cuba: hechos y Cifras." La Habana; Direccion Nacional de Estadisticas.

17. PAHO, Health in the Americas. Washington, D.C. 1998. Vol 1, page 238.

18. Ministerio de Salud Publica (MINSAP). Anuario Estadistico 1998. La Habana, Direccion Nacional de Estadisticas.

19. Juramento de los medicos graduados en el Pico Turquino. Tribuna Medica de Cuba. Vol XXVI, p. 47. 1965-66.

20. PAHO, Health in the Americas. Washington, D.C. 2002. Vol 2, pp 198-212..

21. PAHO, Health in the Americas. Washington, D.C. 1998. Vol 1. Table 32

22. PAHO, Health in the Americas. Washington, D.C. 1998. Vol 1. Table 31.

23. PAHO, Health in the Americas. Washington, D.C. 2002. Vol 1. p. 81.

24. PAHO, Health in the Americas. Washington, D.C. 1998. Vol 1. p. 48.

25. Jordan, J., Ruben, M., and Hernandez, J. The 1972 Cuban national child growth study as an example of population health monitoring: design and methods. Annals of Human Biology. 1975, Vol 2, pp 153-171.

26. PAHO. Health in the Americas. Washington, D.C. 1998. Vol 1, p. 58 and Health in the Americas. 2002. Vol 1, p. 74.

27. PAHO. Health in the Americas. Washington, D.C. 1998. Vol 1, p.70.

28. PAHO. Health in the Americas. Washington, D.C. 1998. Vol 1, p. 49.

29. PAHO. Health in the Americas. Washington, D.C. 2002. Vol 1, p. 75.

30 Benjamin, M. "No Free Lunch: Food and Revolution in Cuba Today. Institute for Food and Development. 1985.

31. Jimenez Acosta, S, Porrata, C, and Perez, M. Evolucion de algunos indicadores alimentario-nutricionales en Cuba a partir de 1993. Rev. Cub. Med. Trop. Vol. 50. 1998 Suppl. Pp 270-272.

32. PAHO, Health in the Americas. Washington, D.C. 1998. Vol 1, Table 21.

33. PAHO, Health in the Americas. Washington, D.C. 2002 Vol 2. p. 200.

34. Torres Pena, R., Joanes Fiol, J., Carreras Corzo, L., Perez Avila, J., et al. L'a infeccion por el virus de inmunodeficiencia humana y la tuberculosis en Cuba. Bol. Oficina Sank. Panam. Vol 119. pp 66-73, 1995.

35. http://www5.who.int/tobacco/repository/stp84/table-a.pdf. Accessed May 4, 2003.

36.Guillen Perez, M., Candelano Madarlaga, M., Cruz Roja, Z., Leonard Castillo, A., et al. Historia obstetrica y uso de metodos contraceptives de las mujeres de un area de salud urbana. Rev. cub. Enferm. Vol 6, pp 88-96, 1990.

37. PAHO, Health in the Americas, Washington, D.C. 1998. Vol 1, p. 114.

38. PAHO, Health in the Americas, Washington, D.C. 1998. Vol 1, Table 33.

39. PAHO, Health in the Americas, Washington, D.C. 1998. Vol 1, p. 193.

40. PAHO, Health in the Americas, Washington, D.C. 2002. Vol 1, p. 209.

41. PAHO, Health in the Americas, Washington, D.C. 2002. Vol 1, p. 370.

42. PAHO, Health in the Americas, Washington, D.C. 1998.

Top

[ Back ] [ Home ] [ Up ] [ Next ]