Health in Cuba

LAENALS: epidemiological and clinical features of amyotrophic lateral sclerosis in Latin America

OBJECTIVE

The Latin American Epidemiologic study of ALS (LAENALS) aims to gather data on ALS epidemiology, phenotype, and risk factors in Cuba, Chile, and Uruguay, to understand the impact of genetic and environmental factors on ALS.

METHODS

A harmonized data collection protocol was generated, and a Latin-American Spanish language Register was constructed. Patient data were collected in Uruguay in 2018, in Chile from 2017 to 2019, and in Cuba between 2017 and 2018. Statistical analysis was performed using SPSS 25.0.0 software. Crude cumulative incidence, standardized incidence, and prevalence were calculated in the population aged 15 years and older.

RESULTS

During 2017-2019, 90 people with ALS from Uruguay (55.6% men), 219 from Chile (54.6% men), and 49 from Cuba (55.1% men) were included. The cumulative crude incidence in 2018 was 1.73/100,000 persons in Uruguay, 1.08 in Chile and 0.195 in Cuba. Crude prevalence in 2018 was 2.19 per 100,000 persons in Uruguay, 1.39 in Chile and 0.55 in Cuba. Mean age at onset was 61.8 ± 11.96 SD years in Uruguay, 61.9 ± 10.4 SD years in Chile, and 60.21 ± 12.45 SD years in Cuba (p = 0.75). Median survival from onset was 32.43 months (21.93 - 42.36) in Uruguay, 24 months (13.5 - 33.5) in Chile, and 29 months (15 - 42.5) in Cuba (p = 0.006).

CONCLUSIONS

These preliminary data from LAENALS confirm the lower incidence and prevalence of ALS in counties with admixed populations. The LAENALS database is now open to other Latin American countries for harmonized prospective data collection.

Trends in mortality patterns in two countries with different welfare models: comparisons between CUBA and Denmark 1955–2020

Cuba and Denmark represent states with different welfare models that have reached the same level of life expectancy. The purpose was to investigate and compare mortality changes in the two countries. Systematically collected information on population numbers and deaths for the entire Cuban and Danish populations was the basis of life table data used to quantify differences in the change in age-at-death distributions since 1955, age-specific contributions to differences in life expectancy, lifespan variation, and other changes in mortality patterns in Cuba and Denmark. Life expectancy in Cuba and Denmark converged until 2000, when the increase in life expectancy for Cuba slowed down. Since 1955, infant mortality has fallen in both countries but mostly in Cuba. Both populations experienced compression of mortality as lifespan variation decreased markedly, primarily due to postponement of early deaths. Given the different starting point in the mid-1900s and living conditions for Cubans and Danes, health status achieved among Cubans is striking. A rapidly ageing population is challenging both countries, but Cuban health and welfare are further burdened by a deteriorating economy in recent decades.

Collective Prevention of Non-Communicable Diseases in an Ageing Population with Community Care

The Dutch population is rapidly ageing, and a growing number of people are suffering from age-related health problems such as obesity, cardiovascular diseases and diabetes. These diseases can be prevented or delayed by adapting healthy behaviours. However, making long-lasting lifestyle changes has proven to be challenging and most individual-based lifestyle interventions have not been effective on the long-term. Prevention programs focused on lifestyle should involve the physical and social context of individuals, because the (social) environment plays a large role in both conscious and unconscious lifestyle choices. Collective prevention programmes are promising strategies to mobilize the potential of the (social) environment. However, little is known about how such collective prevention programs could work in practice. Together with community care organization Buurtzorg, we have started a 5 year evaluation project to study how collective prevention can be practised in communities. In this paper, we discuss the potential of collective prevention and explain the methods and goals of our study.

Educational inequalities and premature mortality: the Cuba Prospective Study

BACKGROUND

Although socioeconomic status is a major determinant of premature mortality in many populations, the impact of social inequalities on premature mortality in Cuba, a country with universal education and health care, remains unclear. We aimed to assess the association between educational level and premature adult mortality in Cuba.

METHODS

The Cuba Prospective Study (a cohort study) enrolled 146 556 adults aged 30 years and older from the general population in five provinces from Jan 1, 1996, to Nov 24, 2002. Participants were followed up until Jan 1, 2017, for cause-specific mortality. Deaths were identified through linkage to the Cuban Public Health Ministry's national mortality records. Cox regression models yielded rate ratios (RRs) for the effect of educational level (a commonly used measure for social status) on mortality at ages 35-74 years, with assessment for the mediating effects of smoking, alcohol consumption, and BMI.

FINDINGS

A total of 127 273 participants aged 35-74 years were included in the analyses. There was a strong inverse association between educational level and premature mortality. Compared with a university education, men who did not complete primary education had an approximately 60% higher risk of premature mortality (RR 1·55, 95% CI 1·40-1·72), while the risk was approximately doubled in women (1·96, 1·81-2·13). Overall, 28% of premature deaths could be attributed to lower education levels. Excess mortality in women was primarily due to vascular disease, while vascular disease and cancer were equally important in men. 31% of the association with education in men and 18% in women could be explained by common modifiable risk factors, with smoking having the largest effect.

INTERPRETATION

This study highlights the value of understanding the determinants of health inequalities in different populations. Although many major determinants lie outside the health system in Cuba, this study has identified the diseases and risk factors that require targeted public health interventions, particularly smoking.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen).

Mental health stigma and professional help-seeking attitudes a comparison between Cuba and Germany

Globally the burden due to mental disorders is continuously increasing. Still, professional help-seeking behavior is not fully understood. To conceive cultural determinants of help-seeking is crucial to reduce personal and social costs of (untreated) mental disorders. The current study investigates mental health stigma and help-seeking attitudes in a Cuban (n = 195) and a German (n = 165) sample. In a questionnaire survey we asked for attitudes towards mental illness and professional help-seeking in the general Cuban and German populations. The cultural context was associated with mental health stigma and professional help-seeking attitudes. Interestingly, Cuban participants reported stronger mental health stigma and more willingness to seek help. In multiple hierarchical regression analyses, community attitudes towards the mentally ill significantly predicted help-seeking attitudes, especially in the Cuban sample. Only in the German sample, more negative individual beliefs about mental illness predicted more self-stigma on help-seeking. Beyond that, cultural context moderated the association between mental health stigma and help-seeking attitudes with a stronger association between the measures in the German sample. However, gender did not predict help-seeking attitudes and self-stigma on help-seeking and no interactions between community attitudes, cultural context, and gender were found in the prediction of help-seeking attitudes. Similarities and differences between the samples are discussed in the light of the cultural contexts and peculiarities of the current samples. Concluding, implications of the current findings are reviewed.

Mortality rates immediately after severe hurricanes in Cuba have decreased over the past three decades

OBJECTIVES

The objective of this study is to understand how Cuba responds to extreme weather events, which can help identify and disseminate good public health practice.

STUDY DESIGN

The study design of this study is an observational study using routinely collected mortality data.

METHODS

National daily mortality counts after severe hurricanes arrived on the Cuba landmass since 1990 were compared with baseline values. Incidence rate ratios of mortality during the hurricane and for the four weeks afterwards were calculated for four eligible hurricanes: Georges (1998), Dennis (2005), Ike (2008) and Irma (2017).

RESULTS

Mortality rates decreased over time (P < 0.001 for interaction), and no excess mortality counts were observed after Hurricane Irma in 2017.

CONCLUSIONS

Mortality rates for severe hurricanes that have made landfall in Cuba have decreased over three decades, despite the most recent hurricane (Irma) being one of the strongest observed in recent decades. This suggests that the Cuban public health preparations and responses to recent severe hurricanes are probably contributing to this mitigation in national mortality rates during these periods.

Gender differences in health in Havana versus in Mexico City and in the US Hispanic population

Health progress in the 1960s and 1970s placed Cuba at the vanguard of longevity in Latin America and the Caribbean. This success has often been attributed to equity of access to the health care system and its cost-effectiveness in the country. Cuba also has a small gender gap in life expectancy. In this study, we examined how this pattern is reflected in the gender differences in health among the population aged 60+ in Havana. We compared gender differences in health in samples drawn from Havana, Mexico City, and the US Hispanic population: three geographic settings with very different political, health care, and social systems. The data come from the Survey on Health, Well-Being, and Aging in Latin America and the Caribbean and the 2000 Health and Retirement Study. Age-adjusted prevalence and logistic regressions were estimated for poor self-rated health, limitations on activities of daily living, depression, and mobility limitations. While an absolute female disadvantage in health was apparent in all three populations, the relative gender differences were inconsistent across all four health domains. Gender differences were most pronounced in Havana, even after adjusting for age, socio-economic status, family characteristics, and smoking behaviour. Despite having higher overall life expectancy and more equitable and universal access to primary care and preventive medicine, women in Havana appear to have a larger burden of ill health than women in less equitable societies. The study provides indirect evidence that Cuba faces challenges in combating the health threats posed by chronic diseases and other diseases and conditions common among the population aged 60+.

Medical training for universal health coverage: a review of Cuba-South Africa collaboration

Achieving improvements in Universal Health Coverage will require a re-orientation of medical education towards a stronger focus on primary health care. Innovative medical curricula have been implemented in some countries, but in many low- and middle-income countries (LMICs), the emphasis remains focused on hospital and speciality services. Cuba has a long history of supporting LMICs and has made major contributions to African health care and medical training. A scheme for training South African students in Cuba was established 20 years ago and expanded more recently, with around 700 Cuban-trained graduates returning to South Africa each year from 2018 to 2022. The current strategy is to re-orientate and re-train these graduates in South African medical schools for up to 3 years as they are perceived to have inadequate skills. This negative narrative on Cuban-trained doctors in South Africa could be changed dramatically. They have highly appropriate skills in primary care and prevention and could provide much needed services to rural and urban under-served populations whilst gaining an orientation to the health problems of South Africa and strengthening their skills. Bilateral arrangements between South Africa and the United Kingdom are providing mechanisms to support such schemes. The Cuban approach to medical education may have lessons for many countries attempting to meet the challenges of Universal Health Coverage.

Causal attribution for mental illness in Cuba: A thematic analysis

Explanatory models (EMs) for illness are highly relevant for patients, and they are also important for clinical diagnoses and treatment. EMs serve to capture patients' personal illness narratives and can help reveal how culture influences these narratives. While much research has aimed to understand EMs in the Western hemisphere, less research has been done on other cultures. Therefore, we investigated local causal attributions for mental illness in Cuba because of its particular history and political system. Although Cuban culture shares many values with Latin American cultures because of Spanish colonization, it is unique because of its socialist political and economic context, which might influence causal attributions. Thus, we developed a qualitative interview outline based on the Clinical Ethnographic Interview and administered interviews to 14 psychiatric patients in Havana. We conducted a thematic analysis to identify repeated patterns of meaning. Six patterns of causal attribution for mental illness were identified: (1) Personal shortcomings, (2) Family influences, (3) Excessive demands, (4) Cultural, economic, and political environment in Cuba, (5) Physical causes, and (6) Symptom-related explanations. In our sample, we found general and Cuba-specific patterns of causal attributions, whereby the Cuba-specific themes mainly locate the causes of mental illness outside the individual. These findings might be related to Cubans' socio-centric personal orientation, the cultural value of familismo and common daily experiences within socialist Cuban society. We discuss how the findings may be related to social stigma and help-seeking behavior.

What is the association between price and economic activity with cigarette consumption in Cuba from 1980 to 2014?

OBJECTIVES

Cuba is a tobacco-producing country that has been economically isolated as a consequence of an embargo imposed by the USA. It has also experienced a severe economic depression in the 1990s after the withdrawal of support by the former Soviet Union. These characteristics provide a unique opportunity to study the relation between large changes in economic activity, cigarette price and demand for cigarettes in a relatively isolated socialist economy.

STUDY DESIGN

This is an observational epidemiological study.

METHODS

Data were obtained on the annual price of a packet of cigarettes and the mean number of cigarettes consumed per adult living in Cuba from 1980 to 2014. Descriptive and regression analysis were used to explore the relationship between cigarette consumption and price in Cuba.

RESULTS

In 1980, the mean price of a packet of cigarettes was 1.53 Cuban peso (CUP) in 1997 prices and the mean annual per capita consumption was 2237 cigarettes. In 2014, the mean price had increased to 5.57 CUP (1997 prices) per packet of cigarettes, and consumption had fallen to 1527 cigarettes per capita. There were significant negative associations between annual cigarette consumption and both price and living through an economic depression. The elasticity was approximately -0.31 with price, and living through an economic depression was also associated with lower consumption of cigarettes (a reduction of 9%, 95% confidence intervals -0.18 to -0.001).

CONCLUSIONS

Higher cigarette pricing, along with other public health interventions, are required to protect the national population from the adverse effects of tobacco smoke exposure.

Generation and characterization of monoclonal antibodies against thyroid-stimulating hormone for newborn screening of congenital hypothyroidism

Congenital hypothyroidism (CH) is one of the most frequent inherited-metabolic diseases in the world, and the main cause of treatable mental retardation in children. Because signs and symptoms of this disease are often scarce and not easily recognizable, newborns are screened for the early CH detection at birth. The Center of Immunoassay (CIE) has developed the UMELISA® TSH Neonatal and UMELISA® TSH to determine neonatal thyroid-stimulating hormone (TSH) levels in dried blood and serum samples. Both reagent kits use the same polystyrene plates coated with anti-β-TSH monoclonal antibodies (MAbs), but one of these is commercially acquired. Obtaining appropriate anti-TSH MAbs at the CIE would guarantee economic independence and security in the production of these kits. Immunization of mice with TSH led to the generation of 7G11E3, an anti-β-TSH IgG1-secreting hybridoma. The high affinity of 7G11E3 MAb and its characteristic epitopic recognition explain its better performance when adsorbed to UMELISA® plates for capturing low amounts of TSH in comparison with the studied MAbs. Performance of assays using polystyrene plates coated with 7G11E3 MAb was studied. Recovery percentages (100.0-106.7% for UMELISA® TSH NEONATAL and 97.3-99.0% for UMELISA® TSH) and intra (5.2-7.9% for UMELISA® TSH NEONATAL and 3.2-5.3% for UMELISA® TSH) and inter (6.6-7.7% for UMELISA® TSH NEONATAL and 5.2-8.0% for UMELISA® TSH) coefficients of variation were similar to the ones described for the commercial kits. Limits of detection and quantification were 1.0 and 3.8 mIU/L for UMELISA® TSH NEONATAL, and 0.3 and 0.6 mIU/L for UMELISA® TSH, respectively. The results also showed high overall concordance between assays (n = 2 019, ρc = 0.90 for UMELISA® TSH NEONATAL and n = 200, ρc = 0.94 for UMELISA® TSH). The 7G11E3 MAb meets the requirements for its use in the plates of UMELISA® TSH kits for CH newborn screening in Cuba. Abbreviations: CECMED, Center for the State Control of Medicaments and Medical Equipment and Devices; CH, congenital hypothyroidism; CIE, Center of Immunoassay; CLSI, Clinical and Laboratory Standards Institute; CV coefficient of variation; DBS, dried blood spots; LOB, limit of blank; LOD, limit of detection; LOQ, limit of quantitation; SD, standard deviation; S_r, repeatability standard deviation; SUMA, Ultra Micro Analytic System; UMELISA, ultramicro enzyme-linked immunosorbent assay.

Health expectancies among non-white and white populations living in Havana, 2000-2004

This study explored the role of skin color in health expectancies by computing average lifetime in self-rated good health and lifetime without functional limitations in activities of daily living (ADL) among non-white and white 60+ adults living in Havana (Cuba) in 2000-2004. The Sullivan method was used to estimate health expectancies. The contributions from the mortality and health effect to the differences in health expectancies were assessed by decomposition. White males aged 60 were expected to live longer in self-rated good health than non-white males, white and non-white females. Most of the differences among males are attributed to the health effect. No differences were found between white and non-white females in expected lifetime in moderate to full ADL functioning while a difference in ADL functioning of 0.8 years favored white over non-white males. The mortality effect accounted for most difference across the two male groups. From age 80, both non-white groups could expect to live longer than their white counterparts. The results showed that skin color is a risk marker of mortality and morbidity among older adults living in Havana. Although health behaviors vary, the differences were not anticipated due to high social equity and equal health care provision in Cuba. This finding calls for further research on health expectancies by skin color that is representative of the Cuban population and includes information on different diseases and conditions.

Assessment of hypertension management and control: a registry-based observational study in two municipalities in Cuba

Background

To determine the prevalence of hypertension treatment and control among hypertensive patients in the Cuban municipalities of Cardenas and Santiago and to explore the main associated predictors.

Methods

Cross-sectional study, with multistage cluster sampling, conducted between February 2012 and January 2013 in two Cuban municipalities. We interviewed and measured blood pressure in 1333 hypertensive patients aged 18 years or older. Hypertension control was defined as blood pressure lower than 140/90 mmHg.

Results

The mean age ± standard deviation (SD) of participants was 59.8 ± 14 years, the mean systolic and diastolic blood pressure ± SD was 130.0 ± 14.4 and 83.1 ± 9.0 mmHg respectively. The majority of patients (91, 95%CI 90–93) were on pharmacological treatment, 49% with a combination of 2 or more classes of drugs. Among diagnosed hypertensive patients 58% (95%CI 55–61) had controlled hypertension. There was no association between hypertension control and gender, age and socio-economic condition. Levels of hypertension control depended on health area and control furthermore was positively associated with post-primary education, not being obese and white ethnicity: adjusted Odds Ratio (95% CI) 1.71 (1.26–2.34), 1.43 (1.09–1.88) and 1.41 (1.09–1.81) respectively.

Conclusions

The observed figures are outstanding at the international level and illustrate that hypertension treatment and control are achievable in a resource-constrained setting such as Cuba. The country’s primary health care approach and social equity in access to health care can be seen as key determinants of this success. Nevertheless, there is still room for improvement, as over a third of patients did not have controlled hypertension.

Burden of hypertension and associated risks for cardiovascular mortality in Cuba: a prospective cohort study

BACKGROUND

In Cuba, hypertension control in primary care has been prioritised as a cost-effective means of addressing premature death from cardiovascular disease. However, there is little evidence from large-scale studies on the prevalence and management of hypertension in Cuba, and no direct evidence of the expected benefit of such efforts on cardiovascular mortality.

METHODS

In a prospective cohort study, adults in the general population identified via local family medical practices were interviewed between Jan 1, 1996, and Nov 24, 2002, in five areas of Cuba, and a subset of participants were resurveyed between July 14, 2006, and Oct 19, 2008, in one area. During household visits, blood pressure was measured and information obtained on diagnosis and treatment of hypertension. We calculated the prevalence of hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or receiving treatment for hypertension) and the proportion of people with hypertension in whom it was diagnosed, treated, and controlled (systolic blood pressure <140 mm Hg, diastolic blood pressure <90 mm Hg). Deaths were identified through linkage by national identification numbers to the Cuban Public Health Ministry records, to Dec 31, 2016. We used Cox regression analysis to compare cardiovascular mortality between participants with versus without uncontrolled hypertension. Rate ratios (RRs) were used to estimate the fraction of cardiovascular deaths attributable to hypertension.

FINDINGS

146 556 participants were interviewed in the baseline survey in 1996-2002 and 24 345 were interviewed in the resurvey in 2006-08. After exclusion for incomplete data and age outside the range of interest, 136 111 respondents aged 35-79 years (mean age 54 [SD 12] years; 75 947 [56%] women, 60 164 [44%] men) were eligible for inclusion in the analyses. 34% of participants had hypertension. Among these, 67% had a diagnosis of hypertension. 76% of participants with diagnosed hypertension were receiving treatment and blood pressure was controlled in 36% of those people. During 1·7 million person-years of follow-up there were 5707 cardiovascular deaths. In the age groups 35-59, 60-69, and 70-79 years, uncontrolled hypertension at baseline was associated with RRs of 2·15 (95% CI 1·88-2·46), 1·86 (1·69-2·05), and 1·41 (1·32-1·52), respectively, and accounted for around 20% of premature cardiovascular deaths.

INTERPRETATION

In this Cuban population, a third of people had hypertension. Although levels of hypertension diagnosis and treatment were commensurate with those in some high-income countries, the proportion of participants whose blood pressure was controlled was low. As well as reducing hypertension prevalence, improvement in blood pressure control among people with diagnosed hypertension is required to prevent premature cardiovascular deaths in Cuba.

FUNDING

Medical Research Council, British Heart Foundation, Cancer Research UK.

Factors affecting medical students' interests in working in rural areas in North India-A qualitative inquiry

BACKGROUND AND OBJECTIVE

The shortage of doctors, especially in rural areas, is a major concern in India, which in turn affects the effective delivery of health care services. To support new policies able to address this issue, a study was conducted to determine the discouraging and encouraging factors affecting medical students' interests towards working in rural areas.

METHODS

This cross-sectional, descriptive qualitative study has been conducted in three states of North India. It comprised six focus group discussions, each consisting of 10-20 medical students of six government medical colleges. The verbatim and thematic codes have been transcribed by using a 'categorical aggregation approach'. The discussions were thematically analyzed.

RESULTS

Ninety medical students participated in the study. The discouraging factors were grouped under two broad themes namely unchallenging professional environment (poor accommodation facilities and lack of necessary infrastructure; lack of drug and equipment supplies; inadequate human resource support; lesser travel and research opportunities) and gap between financial rewards and social disadvantages (lower salary and incentives, social isolation, political interference, lack of security). Similarly, the encouraging factors were congregated under three main themes namely willingness to give back to disadvantaged communities (desire to serve poor, underprivileged and home community), broader clinical exposure (preferential admission in post-graduation after working more than 2-3 years in rural areas) and higher status and respect (achieving higher social status).

CONCLUSIONS

This qualitative study highlights key factors affecting medical students' interest to work in rural areas. A substantial similarity was noted between the factors which emerge from the current study and those documented in other countries. These findings will help policymakers and medical educators to design and implement a comprehensive human resource strategy that shall target specific factors to encourage medical students to choose job positions in rural areas.

The prevalence, clinical status and genotype of cystic fibrosis patients living in Cuba using national registry data

BACKGROUND

We aimed to establish a national cystic fibrosis (CF) registry for Cuba, a developing country.

METHODS

Regional centres that deliver care for all CF patients provided information for a national database.

FINDINGS

The prevalence of CF in Cuba is 26.3 cases per 1,000,000 population. The median age at diagnosis is 2 years, and the median age of the total population was 15 years. Of those aged 16 years or older, the prevalence of Pseudomonas aeruginosa infection was 46%, the prevalence of Staphylococcus aureus infection was 36%, and 80% of individuals were receiving oral azithromycin. The commonest gene mutation was F508del which was observed in 50% of patients.

INTERPRETATION

These data demonstrate that it is possible to establish a national CF registry in a developing country such as Cuba. This provides baseline data to permit evaluation of health care delivery enable the spread of good clinical practice nationally.

Cuba's Strategy Toward Universal Health

After 40 years of the Alma Ata Declaration on primary health care, the Pan American Journal of Public Health published an actualized overview of Cuban policies on health and well-being. It describes the longstanding and successful experience of this socialist country, developed in adverse and complex circumstances. The Cuban case remains one of the leading examples of a comprehensive governmental approach toward population health and well-being. The analysis underscores the essential role of continued political will toward population health.

Neurological signs as early determinants of dementia and predictors of mortality among older adults in Latin America: a 10/66 study using the NEUROEX assessment

Background

Neurodegenerative processes in the elderly damage the brain, leading to progressive, incapacitating cognitive, behavioral, and motor dysfunctions which culminate in dementia. Fully manifest dementia is likely to be preceded by the presence of neurological signs, which could serve as early determinants of dementia and predictors of mortality. The aims of this study were to assess the construct validity of a neurological battery assessed among older adults living in Latin America, and to test the association of groups of neurological signs with dementia cross-sectionally, and mortality longitudinally.

Methods

The 10/66 Dementia Research Group collected information on neurological symptoms via the NEUROEX assessment in population based surveys of older adults living in low and middle-income countries. Data from 10,856 adults participating in the baseline assessment of the 10/66 study and living in Cuba, Dominican Republic, Peru, Venezuela and Mexico were analysed. Exploratory and confirmatory analysis were used to explore dimensionality of neurological symptoms. Poisson regression analyses were used to link groups of neurological signs with dementia at baseline. Cox hazard regression models were used to explore the predictive validity of neurological signs with mortality at follow up.

Results

Exploratory and confirmatory factor analyses revealed four dimensions of neurological signs, which are associated with lesions of specific brain regions. The identified factors showed consistency with groups of neurological signs such as frontal, cerebellar, extrapyramidal, and more generalized gait disturbance signs. Regression analyses revealed that all groups of neurological signs were positively associated with dementia at baseline and predicted mortality at follow up.

Conclusions

Our findings support the construct and predictive validity of the NEUROEX assessment, linking neurological and gait impairments with dementia at baseline, and with mortality at follow up among older adults living in five Latin American countries.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1167-4) contains supplementary material, which is available to authorized users.

The Dark Side of Cuba's Health System: Free Speech, Rights of Patients and Labor Rights of Physicians

This essay questions the achievements and assessments of the Cuban health system. It argues that health policies in Cuba in the past half century have been implemented with limited concern for civil liberties and certain human rights which are considered a core component of a responsive, transparent, and accountable health system. Three cases are discussed in support of this assessment: 1) the persecution of Cuban analysts who questioned the official version of the socio-economic situation of pre-revolutionary Cuba, including the health state of affairs; 2) the harassment and segregation of gays and people living with HIV; and 3) the violation of labor rights of Cuban physicians working in international missions.

[Non-communicable diseases: risk factors and actions for their prevention and control in CubaDoenças não transmissíveis: fatores de risco e ações para sua prevenção e controle em Cuba]

Non-communicable diseases (NCDs) represent one of the greatest challenges for development of the 21st century due to their devastating social, economic and public health impact. The objective of this article are to describe the evolution and risk factors for NCDs in Cuba, mainly in the period 1990-2015, to outline actions undertaken by the Ministry of Public Health of Cuba, and to highlight the most important challenges with a focus on their prevention and control. The information is based on data collected and published by the Directorate of Medical Records and Health Statistics, research on risk factors, other studies and documentation of comprehensive actions. Mortality in Cuba is determined by four major health problems: cardiovascular diseases, malignant tumors, chronic diseases of the lower respiratory tract and diabetes mellitus, which together cause 68.0% of deaths. Cancer presents a growing trend, and chronic kidney disease emerges as a serious health problem. Cuba has a known baseline on risk factors, and hypertension and tobacco consumption are the main factors related to NCDs mortality. In line with the importance of these diseases, there are milestones and interventions with a positive impact, as well as gaps and challenges within the framework of the World Health Organization's Global Action Plan for the Prevention and Control of NCDs.

The Patient-Centered Medical Home as a Community-based Strategy

Increasing attention has been devoted to the important role that primary care will play in improving population health. One innovation, the patient-centered medical home (PCMH), aims to unite a variety of professionals with patients in the prevention and treatment of illness. Although patient perspectives are critical to this model, this article questions whether the PCMH in practice is truly community-based. That is, do physicians, planners, and other health care professionals take seriously the value of integrating local knowledge into medical care? The argument presented is that community-based philosophy contains a foundational principle that the perspectives of health care practitioners and community members must be integrated. Although many proponents of the PCMH aim to offer patient-centered and sustainable health care, focusing on this philosophical shift will ensure that services are organized by communities in collaboration with health care professionals.

Infant Mortality Rate as a Measure of a Country's Health: A Robust Method to Improve Reliability and Comparability

Researchers and policymakers often rely on the infant mortality rate as an indicator of a country's health. Despite arguments about its relevance, uniform measurement of infant mortality is necessary to guarantee its use as a valid measure of population health. Using important socioeconomic indicators, we develop a novel method to adjust country-specific reported infant mortality figures. We conclude that an augmented measure of mortality that includes both infant and late fetal deaths should be considered when assessing levels of social welfare in a country. In addition, mortality statistics that exhibit a substantially high ratio of late fetal to early neonatal deaths should be more closely scrutinized.

"Enticing case study" or "celebrated anomaly"? Policy learning from the Cuban health system

Cuba is regarded as having achieved very good health outcomes for its level of economic development. It has adopted policies and programs that focus on prevention, universal access to healthcare, a strong primary care system, the integration of health in all policies, and public participation in health. It has also established a strong and accessible system of medical education and provides substantial medical aid and support to other countries. Why then, it may be asked, has the Cuban experience not had greater influence on health policies and reforms elsewhere? This article, based on a literature review and new primary sources, analyzes various factors highlighted in the policy transfer literature to explain this. It also notes other factors that have created greater awareness of Cuban health achievements in some countries and which provide a basis for learning lessons from its policies.

Mora‐Faife E, García‐García G, del Valle‐Infante I, Gómez‐Marrero L, Britton J, Fogarty AW. The association of low birth weight with serum C reactive protein in 3-year-old children living in Cuba: A population-based prospective study

OBJECTIVE

Low birthweight is associated with a decreased risk of childhood leukemia and an increased risk of both cardiovascular disease and all-cause mortality in adult life. Possible biological mediators include systemic innate immunity and inflammation. We tested the hypothesis that birthweight was inversely associated with serum high sensitivity C reactive protein assay (hsCRP), a measure of both innate immunity and systemic inflammation.

METHODS

Data on birthweight and current anthropometric measures along with a range of exposures were collected at 1 and 3 years of age in a population-based cohort study of young children living in Havana, Cuba. A total of 986 children aged 3-years-old provided blood samples that were analyzed for serum hsCRP levels.

RESULTS

Nearly 49% of children had detectable hsCRP levels in their serum. Lower birthweight was linearly associated with the natural log of hsCRP levels (beta coefficient -0.70 mg L-1 per kg increase in birthweight, 95% CI: -1.34 to -0.06). This was attenuated but still present after adjustment for the child's sex and municipality (-0.65 mg L-1 per kg birthweight; 95% CI: -1.38 to +0.08). There were no associations between growth from birth or anthropometric measures at 3 years and systemic inflammation.

CONCLUSIONS

Birthweight was inversely associated with serum hsCRP levels in children aged 3 years living in Cuba. These observations provide a potential mechanism that is present at the age of 3 years to explain the association between low birthweight and both decreased childhood leukemia and increased cardiovascular disease in adults.

Decolonization and life expectancy in the Caribbean

Decolonization has brought political independence to half the Caribbean states in the last half of the 20th century, while the other states remain affiliated. Previous studies suggested a beneficial impact of affiliated status on population health, which may be mediated by more favorable economic development. We assessed how disparities in life expectancy between currently sovereign and affiliated states developed over time, whether decolonization coincided with changes in life expectancy, and whether decolonization coincided with similar changes in GDP per capita. Time-series data on life expectancy and related variables, GDP per capita and political status were collected from harmonized databases. We quantified variations in life expectancy by current political status during the 1950-2010 period. We assessed whether decolonization coincided with life expectancy trend changes by: 1. calculating the annual changes before and after independence, and 2. evaluating trend breaks in a predefined period during decolonization using joinpoint analyses. Similar analyses were undertaken for GDP per capita. Life expectancy in currently sovereign Caribbean states was already lower than in affiliated states before political independence. Overall, decolonization coincided with reductions in life expectancy growth, but not with reductions in economic growth, and changes in life expectancy growth in the decade after independence did not correspond with changes in economic performance. The widening of the life expectancy gap between currently sovereign and affiliated states accelerated in the 1990's and continues to increase. Despite considerable life expectancy gains in all Caribbean states, life expectancy in currently sovereign states increasingly lags behind that of states which remained affiliated. Our results indicate that changing economic conditions were not the main determinant of the unfavorable trends in life expectancy during and after decolonization. Circumstantial evidence points to the weakening of bureaucracies during decolonization underlying the uneven life expectancy developments of currently affiliated and sovereign states.

Morbidity, utilization of curative care and service entry point preferences in metropolitan Centro Habana, Cuba

Abstract: First-line health services with a primary health care approach are a strong trigger for adequate health-care-seeking behavior. Research on the association between prevalence of chronic diseases and acute illnesses and use of health services emphasizes the importance of socioeconomic determinants in such patterns of utilization. In a cross-sectional study of 408 families in Centro Habana, Cuba, home interviews were conducted between April and June 2010 to analyze socio-demographic determinants of acute and chronic health problems and use of formal health services. Bivariate and logistic regression models were used. 529 persons reported a chronic disease. During the previous month, 155 of the latter reported an exacerbation and 50 experienced an unrelated acute health problem. 107 persons without chronic diseases reported acute health problems. Age was the strongest determinant of chronic disease prevalence. Adult women and the elderly were more likely to report acute problems. Acute patients with underlying chronic disease used formal services more often. No socio-demographic variable was associated with services use or consultation with the family physician. While the family physician is defined as the system's entry-point, this was the case for only 54% of patients that had used formal services, thus compromising the physician's role in counseling patients and summarizing their health issues. The importance of chronic diseases highlights the need to strengthen the family physician's pivotal role. New economic policies in Cuba, stimulating self-employment and private initiative, may increase the strain on the exclusively public health care system. Still, the Cuban health system has demonstrated its ability to adapt to new challenges, and the basic premises of Cuba's health policy are expected to be preserved.

Population-based weight loss and gain do not explain trends in asthma mortality in Cuba: A prospective study from 1964 to 2014

BACKGROUND

The increase in prevalence of obesity is a possible risk factor for asthma in developed countries. As the people of Cuba experienced an acute population-based decrease in weight in the 1990s, we tested the hypothesis that national weight loss and subsequent weight gain was associated a reciprocal changes in asthma mortality.

METHODS

Data were obtained on mortality rates from asthma and COPD in Cuba from 1964 to 2014, along with data on prevalence of obesity for this period. Joinpoint analysis was used to identify inflexion points in the data.

RESULTS

Although the prevalence of obesity from 1990 to 1995 decreased from 14% to 7%, over the same time period the rate of asthma mortality increased from 4.5 deaths per 100,000 population to 5.4 deaths per 100,000 population. In 2010, the obesity prevalence subsequently increased to 15% in 2010, while the asthma mortality rate dropped to 2.3 deaths per 100,000 population. The optimal model for fit of asthma mortality over time gave an increasing linear association from 1964 to 1995 (95% confidence interval for inflexion point: 1993 to 1997), followed by a decrease in asthma mortality rates from 1995 to 1999 (95% confidence interval for inflexion point: 1997 to 2002).

CONCLUSIONS

These national data do not support the hypothesis that population-based changes in weight are associated with asthma mortality. Other possible explanations for the large decreases in asthma mortality rates include changes in pollution or better delivery of medical care over the same time period.

AME survey-003 A2: on the attractiveness of an medicine career in current China with a survey of 7,508 medical professionals and 443 non-medical professionals

This is a part of the study of AME survey-003, aiming to understand the motivation and attractiveness of a career in medicine in China. The surveys were conducted on DXY platform with 3,564 medical professionals during October 26 to November 20; on Sojump platform with 1,587 medical professionals during October 28 to December 14, and 443 non-medical professionals during November 15 to December, all in 2015. Similar to our previous result, the not regretted participants vs. regretted participants (N/Y) ratio was 1.1 (P<0.01), and there was no significant difference in N/Y ratio between male and female medical professionals. Medical professionals working in class-IIIA hospitals, small township hospitals, or primary care clinics had a relatively higher job satisfaction than those in hospitals of other classes, while lecturer-level attending doctors (zhuzhi yishi) had a relatively lower job satisfaction than doctors of other grades. A large portion of respondents who replied they regretted entered medical profession said they would still like to be in this profession if they could be in their preferred hospital class and specialty. Public health and basic science research staff, anesthesiologists, oncologists had a relatively higher job satisfaction, while accident and emergency physicians, nurses, and pediatricians had a relatively lower job satisfaction. Medical professionals in Yunnan and Gansu ranked consistently high in job satisfaction than other provinces; despite they were not in the economically advanced regions in China. Similar to our previous result, the majority of the participants favored China to open up medical market to qualified foreign medical organizations to take part in fair competition, as well as favor the government to support regulated private hospitals. Pooled data of 7,508 medical professionals with data from AME survey-003 A1 included showed medicine was the top career choice among medical professionals' children (104/508, 20.5%), followed by finance and economics (74/508, 14.4%), and then electronic engineering or computer science (67/508, 13.2%). Among the 443 non-medical professionals, 122 have children who are attending university or have graduated, 12 (9.8%, 12/122) of them are pursuing a career in medicine. For the 100 non-medical professional parents whose children did not study medicine and if a choice could be given to them to start again, 60 parents (54.5%) replied they would support their children to study medicine. Our results consistently show medicine remained an attractive profession in China.

A New Approach to Health Services and Pharmacy in Cuba

In December 17, 2014, U.S. President Barack Obama surprised the world by announcing his intention to enter into negotiations aimed at reestablishing diplomatic relations with Cuba. Since then, expectations and interest regarding the health system of that country have increased. This report focuses on the Cuban health and pharmacy systems from a practical and educational standpoint. Pharmaceutical services, strengths, opportunities, and challenges are described. Cuba's new trends toward patient-centered care are analyzed to provide insights for developing pharmaceutical care practice and implementing policies suitable for practice in all health care settings.

A qualitative study of factors influencing retention of doctors and nurses at rural healthcare facilities in Bangladesh

Background

Bangladesh is a highly populous country with three-quarters rural population. Pressing national shortages in health professionals has resulted in high vacancy rates in rural areas. These are compounded by excessive absenteeism and low retention among nurses and doctors posted to rural locations. This study attempts to ascertain reasons for providers’ reluctance to work in rural and remote areas and to identify ways in which these barriers to appropriate staffing might be resolved.

Methods

This is a qualitative study based on in-depth interviews with healthcare providers (n = 15) and facility managers (n = 4) posted in rural areas, and key informant interviews with health policymakers at the national level (n = 2). Interview guides were written in English and translated and administered in Bengali. The collected data were re-translated and analyzed in English. Braun and Clarke’s thematic analysis approach (data familiarization, coding, identifying and reviewing themes, and producing a final report) was used.

Results

Participants reported poor living conditions in rural areas (e.g., poor housing facilities and unsafe drinking water); overwhelming workloads with poor safety and insufficient equipment; and a lack of opportunities for career development, and skill enhancement. They reported insufficient wages and inadequate opportunities for private practice in rural areas. Managers described their lack of sufficient authority to undertake disciplinary measures for absenteeism. They also pointed at the lack of fairness in promotion practices of the providers. Policymakers acknowledged unavailability or insufficient allowances for rural postings. There is also a lack of national policy on rural retention.

Conclusions

The findings revealed a complex interplay of factors influencing doctors’ and nurses’ availability in rural and remote public health facilities from the perspective of different players in the healthcare delivery system of Bangladesh. In addition, the study generated several possibilities for improvement, including increased allowances and incentives for rural posting; a transparent and fair promotion system for serving in rural areas; enhanced authority of the local managers for reducing worker absenteeism; and improved national policies on rural retention.

Health-system reform and universal health coverage in Latin America

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens--with defined and enlarged benefits packages--and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

The relationship between body mass index and cancer screening utilization among older women in Latin American and Caribbean cities

To examine the relationship between body mass index and cancer screening utilization, we analyzed data from six cities of the Health, Well-Being and Aging in Latin America and the Caribbean Study on 5,230 women aged 60 and older, from 1999 to 2000. We found that underweight women were less likely to have had a mammogram, a breast self-exam, and a Pap smear, relative to normal-weight women. However, overweight or obese women were more likely to have a breast self-exam and a Pap smear. Thus, being underweight had a role for decreased cancer screening utilization among older women in Latin American cities, but not being overweight or obese, which was associated with decreased cancer screening in most previous studies.

Socioeconomic inequality in salt intake in Britain 10 years after a national salt reduction programme

OBJECTIVES

The impact of the national salt reduction programme in the UK on social inequalities is unknown. We examined spatial and socioeconomic variations in salt intake in the 2008-2011 British National Diet and Nutrition Survey (NDNS) and compared them with those before the programme in 2000-2001.

SETTING

Cross-sectional survey in Great Britain.

PARTICIPANTS

1027 Caucasian males and females, aged 19-64 years.

PRIMARY OUTCOME MEASURES

Participants' dietary sodium intake measured with a 4-day food diary. Bayesian geo-additive models used to assess spatial and socioeconomic patterns of sodium intake accounting for sociodemographic, anthropometric and behavioural confounders.

RESULTS

Dietary sodium intake varied significantly across socioeconomic groups, even when adjusting for geographical variations. There was higher dietary sodium intake in people with the lowest educational attainment (coefficient: 0.252 (90% credible intervals 0.003, 0.486)) and in low levels of occupation (coefficient: 0.109 (-0.069, 0.288)). Those with no qualification had, on average, a 5.7% (0.1%, 11.1%) higher dietary sodium intake than the reference group. Compared to 2000-2001 the gradient of dietary sodium intake from south to north was attenuated after adjustments for confounders. Estimated dietary sodium consumption from food sources (not accounting for discretionary sources) was reduced by 366 mg of sodium (∼0.9 g of salt) per day during the 10-year period, likely the effect of national salt reduction initiatives.

CONCLUSIONS

Social inequalities in salt intake have not seen a reduction following the national salt reduction programme and still explain more than 5% of salt intake between more and less affluent groups. Understanding the socioeconomic pattern of salt intake is crucial to reduce inequalities. Efforts are needed to minimise the gap between socioeconomic groups for an equitable delivery of cardiovascular prevention.

What are the main environmental exposures associated with elevated IgE in Cuban infants? A population-based study

OBJECTIVE

Immunoglobulin E (IgE) plays a key role in allergy disease pathogenesis, but little is known about the environmental factors associated with higher IgE levels in infants. The aim of this study was to determine the risk factors for elevated serum total IgE infants living in Havana.

METHODS

Eight hundred and seventy-seven infants provided blood samples. Data on allergic disease symptoms and a wide range of exposures were collected.

RESULTS

The median IgE was 35 IU/ml (interquartile range 13-96). The risk of having an IgE level above the median was higher for children who had been breastfed for 4 months or more (adjusted odds ratio (OR) 1.28; 95% confidence interval (CI): 1.02-1.61) and for children who reported cockroaches in their home (OR 1.30; 95% CI: 1.03-1.63). The risk was lower for children whose mother was in paid employment (OR 0.73; 95% CI: 0.54-0.97 compared with those who did not), for children living in homes where gas and electricity were used for cooking (OR 0.45; 95% CI: 0.32-0.62 compared with electricity only) and for children with domestic pets at birth (OR 0.83; 95% CI: 0.70-1.00). There was no association between paracetamol use and serum IgE levels.

CONCLUSIONS

Associations between gas fuel use and maternal employment indicate that IgE levels in early life are lower in children who may be living in relative affluence. The discrepancy in the effect of early exposure to pets or cockroaches may reflect differences in these allergens, or be confounded by relative affluence. Further investigation of this cohort will determine how these effects translate into the expression of allergic disease in later life.

Risk factors for eczema in infants born in Cuba: a population-based cross-sectional study

Background

There is a concern that allergic disease in childhood is higher than expected in Cuba. The aim of this study was to determine the risk factors for eczema of infants aged 12–15 months living in Havana.

Methods

We used a cross-sectional epidemiological study design. Data on eczema symptoms and a wide range of lifestyle factors were collected by researcher administered questionnaires.

Results

Data were collected on 1956 children (96% response rate), of whom 672 (34%) were reported as having had eczema. Independent risk factors for eczema included young maternal age (adjusted odds ratio (OR) 0.98 per additional year of age; 95% confidence interval (CI) 0.97-0.99), child’s weight (OR 1.13 per additional kg; 95% CI: 1.03-1.25), insect sting allergy (OR 2.11; 95% CI: 1.33-3.35), rodents in the home (OR 1.39; 95% CI: 1.10-1.76), attendance at childcare facilities (OR 1.34: 95% CI: 1.05-1.70) and self-reported mould in the home (OR 1.23; 95% CI: 1.07-1.41). Infant exposure to paracetamol was associated with an increased risk of eczema even after adjustment for wheeze (OR 1.22; 95% CI: 1.03-1.46).

Conclusion

Despite a very different culture and environment, the consistency of these findings with those from more economically developed countries suggests potential causal associations. The association with paracetamol, even after adjustment for wheeze, suggests that intervention studies are required in young infants, to ascertain if this commonly used anti-pyretic medication increases allergic disease.

Risk factors for wheezing in infants born in Cuba

BACKGROUND

Cuba is a unique country, and despite limited economic development, has an excellent health system. However, the prevalence of asthma symptoms in children in Havana, Cuba, is unusually high.

AIM

As early life exposures are critical to the aetiology of asthma, we have studied environmental influences on the risk of wheezing in Cuban infants.

DESIGN

Cross-sectional study.

METHODS

A random sample of 2032 children aged 12-15 months living in Havana was selected for inclusion in the cohort. Data were collected using questionnaires administered by researchers.

RESULTS

Of 2032 infants invited to participate, 1956 (96%) infants provided data. The prevalence of any wheeze was 45%, severe wheeze requiring use of emergency services was 30% and recurrent wheeze on three or more occasions was 20%. The largest adjusted risk factors for any wheeze were presence of eczema [odds ratio (OR) 2.09; 95% confidence interval (CI) 1.48-2.94], family history of asthma (OR 2.05; 95% CI 1.60-2.62), poor ventilation in the house (OR 1.99; 95% CI 1.48-2.67), attendance at nursery (OR 1.78; 95% CI 1.24-2.57), male sex (OR1.52; 95% CI 1.19-1.96) and the number of smokers in the house (P < 0.03 for trend), OR 1.64 (95% CI 1.17-2.31) for three or more smokers in the house compared to no smokers in the household.

CONCLUSION

We have identified several risk factors for any wheeze in young infants living in modern day Cuba. As the prevalence of smoking in the house is high (51%), intervention studies are required to determine effective strategies to improve infant health.