medicc · rojas ochoa, md, phd, mph 28 equity in public health: a challenge for disaster managers...

Volume VII - No. 9 - November-December 2005MEDICCReviewHealth and Medical News of Cuba

Towards Health Equity in Cuba

Cuba’s MDG Progress Report

Equity in Disaster Management

Human Development & Equity In Latin America & the Caribbean TO

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Editor: Gail A. Reed, MS

Associate Editors: Michele Frank, MD

Conner Gorry

Contributing Editors: Diane Appelbaum, RN, FNP, MS

Debra Evenson, JSD

Reporters/Writers: Gail A. Reed

Michele Frank Julián Torres Conner Gorry

Copy Editor/Design: Anna Kovac,

Lithium.Design Studio

Translation: Barbara Collins

Circulation: Diane Appelbaum

MEDICC Review (ISSN 1555-7960) is published

by MEDICC, Medical Education Cooperation with Cuba,

1902 Clairmont Road, Suite 250, Decatur, GA 30033. ©MEDICC, Inc. MEDICC Review is an open access

journal, available online at http://www.medicc.org.

Reproduction authorized with appropriate citation.

Towards Health Equity in CubaVolume VII – No. 9 – November/December – 2005

Editorial

1 The Health Equity Puzzle: No Easy Pieces

Spotlight

2 MDGs & Health Equity in Cuba By Conner Gorry

MR Feature

5 Changes to Cuban Health Care Aim to Extend Equity By Gail A. Reed

8 The Right to Health Care and the Law By Debra Evenson, JDS

MR Interview

9 Francisco Rojas Ochoa, MD, PhD, MPH Professor, Researcher & Author By MEDICC Review Staff

International Cooperation Report

11 Cuban Disaster Doctors in Guatemala, Pakistan By Conner Gorry

Cuban Professional Literature

13 A Monitoring System for Health Equity in Cuba By Abelardo Ramírez Márquez, MD, PhD & Cándido López Pardo, PhD, MPH 21 Human Development and Equity in Latin America and the Caribbean By Cándido López Pardo, PhD, MPH; Miguel Márquez, MD; & Francisco

Rojas Ochoa, MD, PhD, MPH

28 Equity in Public Health: A Challenge for Disaster Managers By Abelardo Ramírez Márquez, MD, PhD & Guillermo Mesa Ridel, MD, MPH

Headlines in Cuban Health

30 Top Story: Hurricane Wilma: Living to Tell the Tale By Conner Gorry

33 China’s Cancer Patients to Benefit from Cuban Biotech By MEDICC Review Staff

34 Biomedical Engineering Degree Debuts in Cuba By Gail A. Reed & Julián M. Torres

34 Cuban Medicine Receives International Recognition By Anna Kovac

International Voices

35 World Disasters Report 2005, Chapter Two: Run, Tell Your Neighbour! Hurricane Warning in the Caribbean A Report by the International Federation of Red Cross & Red Crescent Societies

Beginning in 1960, the Rural Medical Service brought doctors to Cuba´s most remote communities. Photo Courtesy of Granma Archives

1Volume VII - No. 9 - November/December 2005

Easier said than done: much has been written about achiev-ing improved health outcomes across the board, but the challenge remains in the doing.

The context for this issue of MEDICC Review is global-ized frustration, provoked by dismal progress towards the Millennium Development Goals (MDGs) revealed in the Hu-man Development Report 2005, and the September Millennium Summit’s retreat from its responsibility to hasten the rescue of the world’s 1.2 billion poor. Speaking at the Summit on behalf of 132 developing nations in the Group of 77, Jamaican Prime Minister P.J. Patterson put it bluntly: “We have failed to meet the targets we set; poverty and infectious disease re-main rampant…Too many are being left behind in the march towards the MDGs.”[1]

Perhaps most compelling is the Report’s assertion that “for many of the MDGs the jury is now in, with the evidence that a ‘trickle down’ approach to reducing disparities and maintaining overall progress will not work.”[2] As this paradigm is shattered, so too is the assumption espoused for years by international lending and financial institu-tions that growth automatically drives poverty reduction, and a country’s wealth automatically brings health.

They do not, and a growing body of evidence - Cuba’s included - reveals that it is the distribution of that wealth, social cohesion, and the equity with which society’s opportunities are offered that may have far more to do with health than simple GDP.[3]

This is not to disregard the fundamental obstacle that poverty presents to good health. On the contrary. But it does mean that political will, translated into effective “pro-poor” health policies, can trump some key and otherwise deadly non-medical determinants of health. Indeed, poor countries like Cuba are faced with the dual challenge of designing economic policies to overcome their poverty, and health and social policies to defy it. (See Cuba’s approach in this month’s Spotlight MDGs and Health Equity in Cuba.)

This is in fact the essence of the Cuban experience in the search for equitable health outcomes, a search that has been guided by the conviction that universal, community-oriented primary care must be at the heart of the health system, staffed by professionals whose preventive focus also grapples with social determinants.[4,5]

The road to health equity already traveled by Cuba is perhaps best explored in the Latin American context, one of the most unequal regions in the world (Professional Literature: Human Development and Equity in Latin America and the

Caribbean). But the road is also a long one, as our interview with Dr. Francisco Rojas Ochoa and The Right to Health Care and the Law reveal; and there is always more ground to cover (MR Feature: Changes to Cuban Health Care Aim to Extend Equity).

We are especially pleased to publish, for the first time in English, A Monitoring System for Health Equity in Cuba, by Cán-dido López, PhD, and Abelardo Ramírez, MD, PhD, a summary of Dr. Ramírez’ doctoral thesis which he successfully defended shortly

before his death in 2003. A visionary in the field of health equity, throughout his entire professional career Dr. Ramírez devoted his substantial intellect and energies to the pursuit of “health for all” in Cuba.

A second article by Dr. Ramírez, Equity in Public Health: A Challenge for Disaster Managers, cuts to the quick of issues raised by the recent disasters on the US Gulf Coast and in places as far-flung as Guatemala and Pakistan. Cuba’s experience in disaster preparedness and manage-

ment, and contribution to disaster relief efforts globally, is reflected in this month’s International Cooperation Report: Cuban Disaster Doctors in Guatemala, Pakistan and our Top Story, Hurricane Wilma: Living to Tell the Tale. Excerpts from the International Red Cross and Red Crescent Society’s publication, World Disasters Report 2005, shed further light on the theme.

It is our hope that Cuba’s piece will be useful to those strug-gling to solve the puzzle of equitable health outcomes - which is of course, in essence, the puzzle of equitable human development itself.

The Editors

Notes & References:

1. Deen, T. “March Toward MDGs Leaving Millions Behind,” IPS, UN Headquarters, Sept. 16, 2005.

2. Human Development Report 2005. International Cooperation at the Crossroads. New York. UNDP. 2005. p. 52.

3. See the Human Development Report 2005, Chapter 2, the work of Ichiro Kawachi and Bruce Kennedy at Harvard University; Richard Wilkinson, University of Sussex; and Paul Farmer of Partners in Health, among others.

4. Spiegel J, Yassi A. Lessons from the margins of globalization: appreciating the Cuban health paradox. J of Pub Health Pol, Vol. 25, No. I, 2004, p. 110.

5. Tejada de Rivero D. Alma Atá: 25 años después. Pespectivas de Salud, OPS, Vol.8, No. 2, 2003. Washington, DC.

EDITORIAL

The Health Equity Puzzle: No Easy Pieces

“Cuba’s experience challenges the conventional assumption that generating wealth is the fundamental precondition for improving health. As peoples around the world search for cost-effective ways to improve well-being, they might want to learn how alternative public policy

approaches, such as those used in Cuba, may be effective.”[4]

2 MEDICC Review - Towards Health Equity in Cuba

By Conner Gorry

‘We live like the poor, but die like the rich,’ goes the popular Cuban saying – a simple axiom embodying the complex reality of the island’s progress towards health equity. ‘Living like the poor’ refers to the resource-scarce setting (like much of the Global South) that defines Cuba, while ‘dying like the rich’ refers to the diseases – cardiovascular disease, cancer – that are the leading causes of death in Cuba (quite unlike the Global South). The saying should also include being ‘born like the rich,’ since Cuba’s infant mortality rate places it among the privileged worldwide.[1]

Enter the UN Millennium Development Goals (MDGs). De-signed to measure progress towards eliminating extreme poverty by 2015, the MDGs provide a framework for a concerted, global development effort. By measuring 48 indicators, 18 directly re-lated to health, the goals allow individual nations to measure their development progress in several key areas. While their aggregate, outcome-oriented construct has its limitations, the MDGs provide a starting point for understanding how equity and development (both economic and human) interact to affect health, well-being, and sustainability.

Cuba’s MDG Scorecard

Unnecessary, preventable and unjust conditions that foster and perpetuate inequity are known as ‘inherited disadvantages.’ These are social, demographic, geographic or economic circum-stances into which a person is born, and over which they have no control, but which directly affect their ability to improve their personal welfare, stay healthy or simply survive the first five years of life. Exhibiting the political will to offset imbalances in such structural fundamentals that shape every society provides the first link in the chain towards equity in health and human development.

In Cuba, the combination of free and universal health care and education, public participation, and the willingness by the government to implement policies to maximize equity, has had positive effects on health outcomes. At 2004 year’s end, chief national health indicators related to reaching the MDGs included:

• Percentage of births attended by professional staff in health facilities: 99.9%

• Infant mortality rate: 5.8 per 1,000 live births• Under five mortality rate: 7.7 per 1,000 live births• Maternal mortality rate: 38.5 per 100,000 live births• Percentage of low-birth weight babies: 5.5% • Percentage of children under five years old underweight

for their age: 2%• Percentage of children vaccinated against measles:

100% • HIV prevalence rate among 15-24 year olds: 0.05%• HIV prevalence rate among pregnant women: 0.004%• Numbers of children orphaned by AIDS: 3.8 per 1,000

live births • TB prevalence rate: 6.6 per 100,000 inhabitants• Percentage of population with access to affordable es-

sential drugs on a sustainable basis: 95-98%[2]

Taken together with an array of other indicators, this means Cuba has achieved three of the eight MDGs and is on track to achieve another trio by the 2015 deadline (Table 1).

Improving national aggregates in health and other indica-tors, however, is just the first step on the long road towards reach-ing the MDGs for whole populations, and thus promoting health equity. Indeed, reporting a country’s overall outcomes often masks inequity, an explicit shortcoming of the goals as an instrument to measure health achievements and development. “Reporting of national averages for the indicators is a very blunt instrument to use to assess whether or not changes have occurred and to provide

SPOTLIGHT

MDGs & Health Equity in Cuba

Cuba’s Plan Turquino-Manatí posts doctors to remote, rural communities.

The Maternal-Child Program has helped Cuba reach MDG #4.

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sound explanations thereof,” stated a WHO assessment of progress towards the goals.[3]

In the search for those ‘sound explanations,’ Cuba analyzes health outcomes across many variables, including gender and geo-graphic location – two classic inherited disadvantages contributing to inequity.

Vulnerable Populations & Equity

Gender, age, geographic location, and mental and physical disabilities are determinants affecting equity and subsequently, health. In recognition of this, Cuba has designed programs and shaped policy specifically for those populations to provide for their health and boost human capacity. Some examples include:

• Prioritized medications for the elderly, expectant moth-ers and chronically ill – including full ART treatment for all HIV/AIDS patients requiring it;

• A national Maternal-Child Program, which guarantees screening for cervical-uterine cancer, antenatal care, well-baby visits, and immunization against 13 childhood illnesses, among other community-based services;

• Special food allotments for the ill, elderly, expectant mothers, and children 15 and younger who are under-weight for their age;

• Primary care for remote communities, as part of a plan known as Plan Turquino-Manatí;

• Visits by social workers to at-risk households; additional food and financial assistance provided when neces-sary;

• House repair, plus financial and nutritional assistance for hurricane victims; and

• Rehabilitation, job training/placement and in-home assistance for the disabled.

The dual approach of lowering economic and physical bar-riers to access, while providing specific programs for vulnerable populations, has shown positive results across both time and the national territory. The latter is particularly challenging for coun-tries of the Global South, which typically evidence a dichotomy in health indicators within their borders – more positive general outcomes in the capital and big cities, which turn abysmal upon entering the countryside. In this regard, Cuba’s history is no different. But by collecting data and analyzing outcomes across territories, health authorities have been able to target provinces that have traditionally lagged behind the rest of the country, dedicating human and material resources to closing the health equity gap between urban and rural populations (Table 2). As a result, it is not always the City of Havana (considered a province in Cuba’s political/administrative division) that exhibits the best indicators in the country.

Such policy adjustments and resources transferred to tackle internal disparities have contributed to the positive trend in Cuba’s global results over time (Table 3).

Goal Targets Status

#1: Eradicate extreme hunger & poverty

1. Halve the proportion of people living on less than US$1/day2. Halve the proportion of people suffering from hunger

On track to be met by 2015 deadline

#2: Achieve universal primary education

3. Ensure that children everywhere can complete a full course of primary schooling Met

#3: Promote gender equality and empower women 4. Eliminate gender disparity in primary & secondary education Met

#4: Reduce child mortality 5. Reduce by 2/3 the under-five mortality rate Met

#5: Improve maternal health 6. Reduce by 3/4 the maternal mortality rate ratio On track to be met by 2015 deadline

#6: Combat HIV/AIDS, malaria and other diseases

7. Have halted by 2015 and begun to reverse the spread of HIV/AIDS 8. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

On track to be met by 2015 deadline

#7: Ensure environmental sustainability

9. Integrate sustainable dev’p principles into country policies and reverse loss of environmental resources10. Halve the proportion of people without sustainable access to safe drinking water and sanitation11. By 2020 to have achieved a significant improvement in the lives of at least 100 million slum dwellers

Potential to be met by 2015 deadline

#8: Develop a global partnership for development

12. Develop further an open, rule-based, predictable, non-discriminatory trading and financial system13. Address the special needs of the least developed countries14. Address the special needs of landlocked countries and small island developing states 15. Deal comprehensively with the debt problems of developing countries through nat’l & int’l measures in order to make debt sustainable in the long term16. Develop & implement strategies for decent & productive work for youth17. Provide access to affordable essential drugs in developing countries18. Make available the benefits of new technologies, especially information & communication

Potential to be met by 2015 deadline

Table 1: Cuba´s Progress Toward the Millennium Development Goals

Source: Human Development Report 2005


Taken together, Tables 2 and 3 show much progress has been made, and indicate where improvements are needed. Health authorities agree that further attention is needed to implement ag-gressive, systematic approaches that will improve problem areas like maternal mortality, and consistent availability of a nutritious food supply and essential medications. To this end, instruments have been proposed for measuring health outcomes across time, space and population groups to define a more equitable and efficient health policy (see Professional Literature A Monitoring System for Health Equity in Cuba).

In addition, recent adjustments to primary health care in Cuba aiming to tailor services to the local health picture, improve

access, and increase technological and physical capacities of polyclinics and hospitals, indicates continued commitment to equity-driven policy making (see MR Feature Changes to Cuban Health Care Aim to Extend Equity).

Another health challenge looming on the horizon is the graying of the Cuban population due to lower birth and infant mortality rates, longer life expectancies and migration: as of 2003, 15% of the Cuban population was 60 years or older. As this trend continues (by 2025, the figure is expected to reach 25%), existing health, education and cultural programs will have to be reevaluated and new initiatives - especially related to employment and productivity - launched to cope with the effects this will have on Cuban society.

Significantly, Cuba undertakes compre-hensive data collection to define the scope of the population’s health problems – distinguishing it from many countries which suffer from a woeful lack of reliable data. This simple lack of data is hamstringing faster progress towards the MDGs for many countries of the Global South, which Cuba leads in several indicators. Indeed, the island even surpasses many developed nations (Table 4).

By relying on aggregate national data that is neither sensi-tive over time, nor weighted for those nations already evidencing positive outcomes, the MDGs cannot give a true picture of health, relative poverty or development of a country. Furthermore, such collective measurements severely limit comparisons among and within nations. By approaching health as a strategy capable of augmenting both human development and equity, Cuba has brought a fresh perspective to the MDGs and the type of progress that is possible even in resource-scarce settings.

Notes & References

1. In 2004, Cuba had a national infant mortality rate of 5.8 per 1,000 births (National Office of Statistics, 2004), while the United States rate was 6.5 (CIA Factbook, 2004).

2. All figures from “Objetivos de Desarrollo del Milenio: Cuba, Segun-do Informe.” Instituto Nacional de Investigaciones Económicas, Havana, July 2005, pp 38-9.

3. WHO Regional Office for South-East Asia, “Global Perspectives And Issues In Tracking Progress And Measuring Achievements On The Millennium Development Goals,” Bangkok, December 2004.

Province Under 5

Mortality Ratio*

Low-birth Weight

Maternal Mortality**

TB Incidence***

Nationally 7.7 5.5 38.5 6.6

Pinar del Río 6.3 5.6 57 5.2

Havana Province 9.2 5.2 39.6 5.7

City of Havana 8.6 5.3 52.5 7.7

Matanzas 5.8 5.1 30.5 5.0

Villa Clara 6.1 4.8 0 8.1

Cienfuegos 6.5 6.1 0 3.8

Sancti Spíritus 5.9 4.5 0 10.8

Ciego de Ávila 6.9 5.1 20.9 9.4

Camagüey 7.6 5.2 34.2 5.1

+Las Tunas 6 5.8 0 8.7

+Holguín 7.4 5.6 44.8 6.3

+Granma 6.8 5.5 18.2 6.1

+Santiago de Cuba 9.9 6.5 104.7 5.1

+Guantánamo 11.3 5.9 27.5 4.9

Table 2: Key Health Indicators by Province, 2004

Source: Instituto Nacional de Investigaciones Económicas, July 2005*per 1,000 live births**per 100,000 live births***per 100,000 inhabitants+Indicates provinces in historically lesser-developed Eastern Cuba.

Indicator 1994 2004

Proportion of births attended by skilled health personnel

99.8 99.9

Low birth weight (%) 8.9 5.5

Premature birth mortality rate* 4.0 2.1

Infant mortality rate* 9.9 5.8

Under 5 mortality rate* 12.8 7.7

Maternal mortality rate** 57 38.5

Reported AIDS cases*** 23.1 17.3

Table 3: Selected Health Indicators, Cuba 1994 & 2004

Source: Anuario Estadístico de Salud*per 1,000 live births **per 100,000 live births***per 1,000,000 inhabitants

Region Infant Mortality*

Under 5 Mortality*

World 56 81

Most developed 8 10

Developing 61 89

Least developed 97 161

Latin America & Caribbean 32 41

Cuba 5.8 7.7

Table 4: Cuba vs Selected Regions in Infant & Under 5 Mortality, 2005

Source: United Nations, 2003 and Anuario Estadístico de Salud*per 1,000 live births


By Gail A. Reed

“You can’t quarrel with results,” goes the old saying. After all, at 5.8 per 1,000 live births, infant mortality in Cuba is the lowest in the region; its other indicators are in similar good shape, show-ing less internal disparities than even many developed countries; and its health and social policies have emerged from the test of fire of the 1990s, holding the line on health advances despite that decade’s economic free-fall.

International health policy studies are beginning to take note of these results and the Cuban health system’s track record, from vaccine development and physician training to preventive medicine.[1,2] “Cuba applies the principles of the Alma Ata (1978) Declaration - Health for All with a primary care focus - more thoroughly than anywhere else,” notes a recent article in the Journal of Public Health Policy.[3]

Yet, true to the historic ‘dy-namic of dissatisfaction’ that has propelled Cuba’s health movement over the years, Cuban health profes-sionals, authorities and government are shaking up the system again. The question is the same: how to improve the population’s health status? But it’s the search for answers that goes deeper, with big implications for 11 million Cubans at the center of what promises to be a profound functional reform.

Catalysts for Change

Since the 1960s, the Cuban government has taken respon-sibility for building a health care system based on principles of universal coverage and equitable access, with the emphasis on community-oriented preventive care. At the primary level, where international studies indicate up to 80% of health issues can be addressed, Cuban services have consistently been moved closer to the population - in the early years through doctors travelling to rural zones, and later, through the building of community-based polyclinics (see MR Feature Bringing Services Closer to Home in MEDICC Review Vol. VII, No. 5, 2005). In the 1980s, the system’s reach was further extended with the family doctor-and-nurse team, who live and work in the neighborhood they serve. Now provid-ing care to 99.4% of the Cuban population, each is responsible for the health of 150-200 families - the family being the basic focus of a holistic concept of attention to individuals, families and the neighborhood.[4,5,6]

Family doctors undertake preventive education, with the help of nurses and local activists; counsel, diagnose and treat

patients in their offices; make house calls; and carry out con-tinuous assessment of major health problems and risk factors. As a result, patients’ collective medical records yield an annual neighborhood health diagnosis. Anywhere from 20 to 40 of these doctor-nurse teams are clustered around the community poly-clinic, the hub that now provides referral services in other fields, such as pediatrics, ob-gyn, geriatrics, psychiatry, etc., offering another dimension to comprehensive primary care. Secondary

and tertiary facilities (includ-ing institutes dedicated to specific pathologies), com-plete the health care delivery model, offering more special-ized care for complex health problems.

Over the years, says Dr. Joaquín García, Vice Min-ister of Health for Medical Attention, “we were seeing disparities in health outcomes consistently reduced - both by improving social determinants of health and health services. The gap was closing and yield-ing more positive and equita-ble results.” So, for a time, the

‘one size fits all’ family doctor-polyclinic-hospital model seemed to fit the bill. But now, other changes are prompting deeper analy-sis, and suggest that once a certain plateau of positive outcomes is reached, equality in services does not assure further positive, equitable gains in either patient access or outcomes.

Take just two variables in Cuba today: aging of the popula-tion and availability of transportation. As a result of increased life expectancy and decreased birth rates across the island, Cuba’s population is one of the fastest aging in Latin America, with 15.4% of its population over 60 years old.[7] Improvements in health status mean these seniors are not only living longer, but are also vulnerable to the chronic diseases that appear later in life. Simply put, there are more older people needing health services more often than younger people for prevention, treatment and rehabilitation. Enter the transportation crisis, especially in Havana (pop. 2.2 million), where the vast majority of residents without private vehicles depend on public buses that often leave them waiting for hours, passengers so crammed into SRO coaches that a local artist used Picasso’s Guernica as a billboard metaphor for the experience.

So, having the cardiologist or physical rehabilitation services only available at hospital level might be enough for the 30-year-olds in a particular community, but may be too far away to be of real help to the growing vulnerable population of aging heart patients who most need them - thus generating inequity.

MR FEATURE

Changes to Cuban Health Care Aim to Extend Equity

Pediatric allergy testing services at the refurbished Heroes de Girón Polyclinic, Cerro Municipality, Havana.

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The aim of the current analysis - which has resulted in a pilot program already under way in Havana’s municipali-ties - is to shape health services at the local level to prioritize the most pressing health problems in each place. Thus, the constellation of specialized services offered at one polyclinic may be different from another’s, and only resemble each other to the extent that the community health diagnosis in each place reveals a similar set of major health problems and risk factors. The purpose is to use the interplay of health indica-tors and levels of care as guides for action, moving the right amount and type of resources to where they can be used most rationally, and above all, are most accessible to the patients who need them.[8]

All this requires better integration, harnessing the dif-ferent capabilities at the secondary and tertiary, as well as the primary level, and putting them to work more closely together. “The main point, however,” says García, “is to improve people’s health, not to make changes in the system for better flow charts. The idea is to measure what we do more consistently against results we obtain in health status: not how many people visited the ophthalmologist, but rather how many people recovered their vision.”

Suit the Patient

In the new design being piloted first in Havana, the following approach is being applied:

• The central focus is the patient - meaning greater accessibility to services required. “People have to feel accessibility, it has to touch them,” insists Dr. Yamila de Armas, Municipal Health Director in Havana’s Cerro Municipality where the pilot program began over a year ago.

• The main planning and impact assessment instrument is the territorial health diagnosis, using incidence and prevalence to reveal main pathologies and risk factors within specific geographic boundaries (municipalities and communities within them). This epidemiological tool is used to re-orient resources and services in the com-munity and municipality, its data serving as benchmarks against which the results of decisions and interventions will be measured.

• The key decision-making level is the municipality. In the new design, the authority of the Municipal Health Director is buttressed by mandating and empowering her to convene a Municipal Health Commission, composed of directors of all health services in the municipality, includ-ing even tertiary care facilities. She also has the discretion to involve any other institution whose activity influences health status (sanitation department, waterworks, etc.).

• The approach is a problem-solving one, in which the Municipal Health Commission uses the area’s health diagnosis to develop an action plan around the main health problems, promoting grassroots participation in this process through local government. Objectives, actions, and responsibilities are defined, as well as the short- and medium-term impact indicators to be adopted for later evaluation.

• The Municipal Health Commission develops an inte-grated approach to resource management, agreeing which human, material and financial resources must be moved and to where, to carry out the actions decided - drawing on the local hospitals, polyclinics, family doctor teams, pharmacies, hygiene and epidemiology depart-ments, etc.

• The community polyclinic becomes the hub of the entire health system, as backup for the family doctors, who will still function as “guardians of health” for smaller population cohorts. The number of patients assigned to the family doctor-and-nurse team may eventually shift in this ongoing process, depending on population density, geographical remoteness of patients from other health care facilities, and the possibility of a fuller role for family nurses.

The polyclinics have already become a major training scenario for physicians, nurses and other university-level health sciences careers, giving them a more robust academic role and more cross-generational professional depth on their staffs.

This is not yesterday’s paint-peeling polyclinic, its potential sapped by economic woes. As a result of Cuba’s modest economic recovery and policy decisions, over 440 polyclinics across the island were completely refurbished by 2004, adding new technol-ogy and new services - including ultrasound and other imaging, endoscopy, ophthalmology, a greater range of lab tests, natural

Before and after: the Lidia Doce Pavilion at the Salvador Allende Teaching Hospital, refurbished under the “centers of excellence” initiative.

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and traditional medicine departments, physical therapy, plus information technologies.

• Hospitals and tertiary facilities tend to be reserved for more complex procedures, cases and treatments, their specialists offering services at polyclinic level when it is deemed necessary. To tackle the legacy of neglect spanning more than a decade that left many hospitals virtually in ruin, government has launched a Herculean investment program, ”to essentially rebuild 52 major institutions, revolutionizing their technology,” notes Dr. García, transforming them into national centers of excellence for both Cuban and international patients. “We could choose to solve this problem now, with simultaneous investments, or we could have done it over 20 years,” he says. “We decided to do it now.”

There is no doubt that the current pilot program to re-orient care, the mammoth investment programs and the assign-ment abroad of over 25,000 of Cuba’s 70,000 physicians, bring some turbulence to the system, and with it, logical patient dissatisfaction. In addition, Dr. García notes that the historic gaps between primary, secondary and tertiary care that the new integrated design aims to close could still be felt by patients until the pilot becomes a fully functional model.

But, says Dr. De Armas, in the Cerro Municipality, where it all began, the shift to “tailor-made” services has already taken place. “In Cerro, we’ve used the health diagnosis to determine a number of new specialized services now offered at our four polyclinics, corresponding to the health picture in each of their surrounding communities. For example, as we looked at figures for smokers in the municipality, we discovered that it wasn’t enough to have a psychiatrist on board - but that we had to refine that service, and offer a special ‘smokers’ clinic’ at least one day a week. In one community, we also decided that the growing problem of obesity merited a multidisciplinary service at the polyclinic for referrals from family doctors in that area. Depending on the human resources on hand, the staff comes from the polyclinic itself or is seconded from local hospitals. We now have 28 specialists and 33 services offered at Cerro’s polyclinics.”

Figure 1 offers a snapshot of how some of these 33 ser-vices are distributed.

While it is still too early to measure impact on health out-comes, preliminary indicators show that patients are increasingly relying on the polyclinic rather than the hospital for the diagnos-tic, therapeutic and emergency services newly available at this primary care level.[9]

Pitfalls for the new design? “They are many,” Dr. García told MEDICC Review. “First we have to remember that we are a country in the Third World. We still have challenges when it comes to hygiene and sanitation, to nutrition, and we have to keep in mind that the actions we take have to be feasible, and progressively applied depending on our economic possibilities. We have to keep our feet on the ground. And we have to make sure that the process doesn’t become bureaucratized - that would be suicide.”

Notes and References

1. Cuba’s international health workforce. In: Human Resources for Health – Overcoming the Crisis. Joint Learning Initiative. Global Equity Initiative, Harvard University, 2004, p. 110.

2. Thorsteinsdóttir H et al. Cuba--innovation through synergy. In: Nature Biotechnology, 22, DC19-DC24 2004. http://www.nature.com/cgi-taf/DynaPage.taf?file=/nbt/journal/v22/n12s/full/nbt1204supp-DC19.html.

3. Spiegel JM, Yassi A. Lessons from the margins of globalization: appreciating the Cuban health paradox, J Pub Health Pol, Vol. 25, No. 1, 2004, p. 97.

4. Rojas Ochoa F. Origins of Primary Health Care in Cuba, MEDICC Review, Vol. 6, No. 2, Nov. 2004. http://www.medicc.org/med-icc_review/1104/pages/cuban_medical_literature.html

5. Presno Labrador C, Soberat F. 20 Years of Family Medicine in Cuba, MEDICC Review, Vol. 6, No. 2, Nov. 2004. http://www.medicc.org/medicc_review/1104/pages/spotlight.html

6. Cuba: 10 años después de la Conferencia Internacional sobre la Población y el Desarrollo, Centro de Estudios de Población y Desarrollo (CEPDE), Oficina Nacional de Estadísticas, Havana, 2005, p. 91 Data for 2004.

7. Only Uruguay with 17% and Barbados at 13.1% come close to Cuba’s population structure. See Cuba: 10 años después de la Conferencia Internacional sobre la Población y el Desarrollo, Centro de Estudios de Población y Desarrollo (CEPDE), Oficina Nacional de Estadísticas, Havana, 2005, p. 35.

8. Returning to the issue of transportation, underlying the Cuban approach is also an attempt by the health system to compensate for certain negative social determinants of health.

9. De Armas Y. Integración Policlínico-Hospital, Municipio Cerro, Ciudad Habana, Feb., 2005. PowerPoint presentation.

Figure 1: Sample of Actions for Selected Communities, Cerro Municipality, Havana

Specialized Service Freq. Polyclinic

Hypertension, cardiovascular conditions 1 x week

A. SantamaríaH. GirónA. Maceo

Diabetes, associated pathologies 1 x week

A. SantamaríaH. GirónA. Maceo

Asthma, respiratory conditions 1 x weekH. GirónA. SantamaríaCerro

Obesity and hyperlipidemia 1 x week H. Girón

Breast pathologies 1 x week H. GirónA. Maceo

Ophthalmology 2 x week All four

Cardiology 1 x week All four

Neurology, adult and pediatric 1 x month All four

Smokers clinic 1 x week A. SantamaríaA. Maceo

HIV/AIDS counseling 2 x week All four

Menopause 1 x week A. Maceo

Infertility 5 x week H. Girón Source: Y. de Armas, “Integración Policlínico-Hospital, Municipio Cerro, Ciudad Habana,” Feb., 2005. PowerPoint presentation.


By Debra Evenson, JDS

Although not unique in its inclusion of the right to health care as part of the law of the land, the Cuban Constitution is distinct in both breadth and detail. The Constitution, adopted in 1976[1], obligates the State to assure that there shall be “no sick person who does not receive medical attention.”[2] It also articulates spe-cific obligations of the State to provide a full range of universally accessible health services free of charge, as well as to guarantee the promotion and protection of the health of individuals.[3] Thus, as early as 1976, Cuban law estab-lished a constitutional framework for the development of a compre-hensive and universal program of health services.

Article 50 stipulates that all Cubans are entitled to receive free medical care and to have their health protected. It also enumer-ates the obligations of the State to provide medical and hospital care free of charge, including dental care, prophylactic services and access to specialized centers. In addition, the Constitution em-bodies Cuban public health policy grounded in preventive care, specifying that the State shall develop plans for health education, programs for periodic medical examinations, immunization and other preventive measures.

Other provisions of the Constitution relate to health rights and guarantees for specific populations. For example, Article 43 establishes that all citizens have the same right to receive medical attention without regard to “color of skin, gender, religious belief, national origin and any distinction harmful to the dignity of man.” Other provisions provide for protection of the health and safety of workers (Article 49) and assistance to the elderly (Article 48). In order to ensure maternal and infant health, the Constitution provides that pregnant working women shall be guaranteed paid leave before and after birth.

Cuba’s Public Health Law

The express premise of the Public Health Law, adopted in 1983,[4] is that the protection and improvement of the health of the population is a fundamental and permanent obligation of the State. The law entrusts the Ministry of Public Health (MINSAP) and other institutions to organize and provide health services, and to assure that services are made available free of charge in all parts of the country, including rural areas. The services and preventive programs include not only those required to preserve life and general physical health, but mental and dental health as well. Article 4 sets out guiding principles for the organization of the Cuban health system, including:

• The recognition and guarantee of the right to medical treatment and protection for all citizens in all parts of the nation;

• Health services to be provided by state institutions free of charge;

• The social character of the practice of medicine;• High priority given to preventive measures and ac-

tions;• Public health planning;• Application of scientific and medical advances to health

care;• Active public participation in health activities and plan-

ning; and• International cooperation in health, including provision

of health services to other countries.

With respect to preventive activities, the law requires the institutions that form part of the National Health System to develop health education programs and to pay particular attention to health issues arising in the work place. Thus, the law mandates that workers receive pre-employment medical exams where appropriate, as well as periodic examinations when they are subjected to particular job-related health risks.

In addition, work places are required to adopt measures necessary to prevent work-related injuries and illnesses. Pursuant to the Labor Code, employees are entitled to stop working whenever protective gear or equipment is inadequate or lacking.

The statement in the Public Health Law that medical practice has a social character reflects a 1964 law passed at the request of the assembly of medical students at the universities of Havana and Oriente obliging future graduates to serve only in the public sector, rather than private practice. The law also set up an obligatory two-year social service requirement following graduation.[5] Consistent with this, since 1965, when the first post-revolutionary medical graduates received their diplomas, medical students have taken an oath renouncing private practice (for the oath from this year’s graduating class, see Cuban Disaster Doctors in Guatemala, Pakistan). In the 1965 oath, graduates also committed to serving two years in the Rural Medical Service, the first national program to extend health care to people in the most remote areas of the country.

Rehabilitation of persons suffering from physical or mental disabilities is also set forth in the Public Health Law, mandating that rehabilitation services be designed to restore patients to an active and productive life. In addition, MINSAP is required to work with the Ministry of Labor and Social Security, the Ministry of Education, the unions and various civil organizations to develop rehabilitation programs. Current labor regulations call for special affirmative efforts to provide employment to the disabled.[6] In 1995, these were embodied in a national Program for the Employment of the Disabled (PROEMDIS), intended to both identify and create employment op-portunities for persons with mental and physical disabilities.

Social Security

In addition to the Public Health Law, Cuba enacted legislation in February 1959 - about one month after the revolutionary government came to power - to provide social assistance to those in need.[7] Current law provides special

MR FEATURE

The Right to Health Care and the Law

The Constitution, adopted in 1976 obligates the State to assure that there shall be “no sick person who

does not receive medical attention.” The document also establishes a number of substantive rights in

addition to health care, including the right to a job, access to sports and

culture, and education.


assistance (services, nutritional supplements, and financial aid), for those in particular need. Among the vulnerable groups specifically mentioned are the elderly, persons unable to work and single mothers who require special assistance.

Maternal and Infant Health

Cuban law provides a generous foundation for national health policies directed at insuring the health of newborns and their mothers, and in this context, also addresses gender equality by providing support and guarantees to working mothers. Cuba’s maternity leave legislation grants women 18 weeks fully paid leave, during which their employers are required to hold their jobs. Women are required by law to stop working at 34 weeks into their pregnancy, and take a fully paid leave until delivery. Expectant mothers are also entitled to paid time off from work for antenatal care, and once the child is born, for regular pediatric care during the infant’s first year of life.[8] In addition, labor laws protect women from engaging in harmful on-the-job activities and require they be assigned other duties during pregnancy. For details on maternity leave and the National Program for Maternal-Child Health (PAMI), see MEDICC Review “Pediatrics: The First Year of Life in Cuba” (Vol. VII, No. 6, 2005).

The Broader Framework

Under the Cuban Constitution, citizens have the right to equal treatment under the law, without regard to gender, race, national origin, religion or other characteristics.[9] The document also establishes a number of substantive rights in addition to health care, including the right to a job, access to sports and culture, and education.[10] These provisions

commit the State to take affirmative steps to fulfill the rights described.

The Constitution obligates the State to offer free education from grade school through university and post-graduate studies, thus eliminating the most important economic barrier to formal learning opportunities. This lays the basis for a universally educated citizenry, considered by international health authorities to be a key requisite for a healthy population.

Notes & References

1. Constitution of the Republic of Cuba, 1976 as amended in July 1992.

2. Article 9.3. Article 50.4. Law No. 41, August 15, 1983. A new Public Health Law is currently

being drafted and is expected to be issued soon. 5. Law No. 1141, January 11, 1964.6. Resolution No. 51 (Regulation for the implementation of

Employment Policy), December 20, 1988 (CETSS).7. Law No. 49, February 6, 1959.8. Law on the Maternity of the Working Woman, Decree-Law No.

234, August 13, 2003. This law repeals and substitutes for Law No. 1263 of January 16, 1974 as amended. The law also permits the father to take a leave of absence instead of the mother during the infant’s first year of life enabling the woman to return to work.

9. Articles 41-44.10. Articles 45-52.

The AuthorDebra Evenson, JDS, is a Contributing Editor to MEDICC Review, and the author of Law and Society in Contemporary Cuba.

By MEDICC Review Staff

When he recently received the Pan American Health Organization’s Health Administration award, Dr. Francisco Rojas Ochoa described his early service in Cuba’s remote mountain communities – becoming one of the first doctors seen by many of his patients - as one of the most profound experiences in his career (see Headlines Cuban Medicine Receives International Recognition). This is quite the paean from an educator and administrator who is Distinguished Professor at the Higher Institute of Medical Sciences and National School of Public Health in Havana, a member of the Cuban Academy of Sciences, Editor of the Cuban Journal of Public Health and consultant to PAHO, the World Health Organization and the United Nations Population Fund.

As Director of the Institute for Health Development (1977-81) and co-author of Salud Para Todos, Sí es Posible (Health for All, Yes, It’s Possible), Dr. Rojas Ochoa has dedicated a lifetime

career to contemplating the health equity puzzle. He shared his views recently with MEDICC Review.

MEDICC Review : In your experience, how has Cuban policy - in general and in health care - addressed inequity over the years?

Francisco Rojas Ochoa: I think the first important blow against inequity in Cuba was the Agrarian Reform [in the early 1960s], which among other things, dramatically reduced centuries-old, chronic unemployment. As a result, unemployment dropped from over 12% to

less than 2% in just a few years. The unemployed live in poverty; many of them in extreme poverty. As far as I’m concerned, the fight against poverty is foremost in the struggle against inequity.

General laws also came into play, lowering rents, electricity rates and medication prices. Development of health care services and the education system also began at that

MR INTERVIEW

Francisco Rojas Ochoa, MD, PhD, MPH Professor, Researcher & Author

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time, first with the literacy campaign, and then extending primary education throughout the country. Increasing people’s education level strengthens their cultural formation, and ultimately, is a powerful weapon in the struggle against inequity.

Almost since its creation, Cuba’s health system has made efforts to root out unfair and avoidable inequalities. The first major reform was the creation of Cuba’s first public health program – the Rural Medical and Social Services – in January 1960. Until then, there were virtually no physicians in the countryside; they hadn’t been willing to go there, preferring to work in the private sector. But rural people couldn’t afford private medical care, and there were no public services for them either. This program gave them access to health services. All physicians who graduated that year went to work in the countryside, providing their services to everyone for free; even medicines were free. Free health care in the cities came later.

Soon after came the programs aimed at protecting the health of mothers and their children. In 1972, the first maternity home was created. There are over 200 in Cuba today. These are centers where at-risk pregnant women are looked after, their well-being ensured before delivery. By 1978, all in- and out-patient services were provided universally and free of charge, thus eliminating economic barriers to access.

MR: How does this relate to vulnerable populations?

FRO: Vulnerable populations include the elderly, women, the poor, and the unemployed, among others. A number of initiatives have been taken to address equity in health care for these groups. Sometimes, it has been by changing laws, other times by creating new services.

One example: today the elderly account for over 15% of the Cuban population, and their number is increasing, generating concerns about their vulnerability. As a result, health service reforms have been continually introduced to cater to their needs and well-being (see MR Feature Changes to Cuban Health Care Aim to Extend Equity). This includes the creation of a center for research on health and the elderly - the Ibero-American Center on Aging (CITED) - and social security reforms. An increase in pensions was mandated this year, as a response to the rising cost of living and a new job initiative allows retired people still willing and able to work to do so, while still receiving their pensions.

Elder care home capacities have also increased, and major repairs made to improve their conditions. However, many of us in the public health sector believe that old age homes are not the answer. We need to work harder to recover the tradition of Cuban families looking after their elders. Today we find more younger families who don’t want to live with their elders and try to send them away to old age homes. Alternatives have been introduced, such as daytime centers, where the elderly can go and be looked after during the day and then return to their families in the evening, maintaining the family connection.

MR: Where do you see room for improvement in the Cuban health system’s approach to equity?

FRO: I think we still need to work hard to improve the relations between health care workers and the population. I think this is one of the essential ethical responsibilities of public health service providers.

Since last year, we’ve been holding “Ethics Dialogues” - meetings with hospital and polyclinic staff and other health workers to discuss how to optimize their relationship with patients. There have been complaints from both health care workers and the population about each other’s behavior. Sometimes these complaints are based on tangible issues. Every effort is being made to improve the physical conditions of our facilities, for instance: hospitals and polyclinics that were in very bad shape have been – and are being – repaired. When physical conditions are bad, the workers may not feel like doing a good job or may be disgruntled. We’re doing our best to address this problem. But nicely decorated hospitals or the most sophisticated medical equipment aren’t enough if health professionals and technicians don’t treat their patients correctly and compassionately.

I think this is an area where very hard work is still to be done, and it will take us a long time, maybe years, particularly with [our medical] students. We have to ensure that the ethical principle of a good doctor-patient relationship is sufficiently emphasized in their training. Cuban doctors now serving in other parts of the world, in very poor nations – in the countryside, in mountainous areas, in the remotest places of Africa or Central America – have established excellent relations with their communities and patients. There they are faced with a different reality; they learn many things, in particular about interpersonal relationships, and they return home with a more comprehensive and solid formation. And this benefits us all. These people go to work in other countries for two or three years, but then they return home and work here for 30, 40 or 50 years. So, we’re not only giving, we are receiving benefits as well.

MR: Do you think the Cuban model is replicable in other countries?

FRO: What we call the Cuban approach, the Cuban health care model, I would say is not replicable, if we understand “replicate” as making an exact copy. Two countries will never be able to replicate each another’s ways of doing things. Certainly, some of our experiences can be considered, analyzed and adapted to the reality of another country, mainly in terms of what the Cuban government has done to fight inequity in health, but trying to replicate someone else’s ways of doing things can be risky.

I would say in recent years, we’ve been working on creating our own ideas, and looking into the work done in health care in the rest of Latin America. We believe there is a Latin American way of thinking with respect to the delivery of health care and social services.

The Rural Medical Service brought health care to Cuba’s most remote reaches.

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By Conner Gorry

Mothers swing pick axes and claw at the mud, searching for loved ones buried in the rubble. Rotting corpses and shortages of food, water and medicine threaten survivors, while relief efforts are hampered by impassable roads or inclement weather. This same, desperate scene is repeating itself from Guatemala to Pakistan, where catastrophic natural disasters have shaken these nations to the core.

The aftermath is horrific, with entire communities entombed in Guatemala and Pakistan, while nearly 1,000,000 are displaced in Mexico and a dengue outbreak grips El Salvador in separate post-disaster scenarios. To help save survivors of such events is the goal of Cuba’s Henry Reeve International Team of Medical Specialists in Disasters & Epidemics.

Units of this specialized, rapid response volunteer team of health professionals are now serving in Guatemala and Paki-stan, their expenses assumed by the Cuban government.

Conceived during Hurricane Katrina as a mobile team staffed with doctors trained in disaster response and epidemic intervention, the 1,586 medical professionals- each equipped with 50 pounds of medicines - pledged to serve anywhere in the world they were needed (see MEDICC Review, Vol. VII, No. 8, 2005).

In a ceremony on September 19, Cuba formally constituted the International Team, the founding members of which collectively possess an average of 10 years clinical experience and service in 43 countries. Ultimately, the United States rejected Cuba’s offer to send these medical professionals to the Gulf States during the ongoing post-Katrina relief effort.

MR: What hurdles do you see for other countries work-ing towards health equity?

FRO: The heart of the struggle for health equity is the de-velopment of public, state-funded services which are provided free of charge, or at very low cost, to the whole population. Whenever a country, government or society opts to depend on private health services or private health insurance, they are breeding inequity, since not many people will be able to afford these services. No developed or highly developed nation has so far stamped out poverty, so I believe the answer is a state-funded public health service – where the term “public” means accessible to all, free of charge or at very low cost. This can be a first step.

A second step would be to regulate medicine prices. As long as the pharmaceutical industry remains an incredibly powerful, transnational for-profit business, which sells vital medicines at inflated prices well above the real cost of production, this will be a source of inequity. Until governments intervene in the regulation of medicine prices, huge inequities will continue. A well-known example is antiretroviral drugs for people with HIV/AIDS. The production cost for these drugs is a fraction of what they’re sold for. Some governments have challenged these policies by manu-facturing generic drugs. Countries like Brazil and South Africa have dramatically reduced costs of antiretroviral drugs, making them accessible to many patients who could not otherwise afford them. In Cuba, antiretrovirals are dispensed free of charge to all AIDS patients who need them.

Another priority of the Cuban government has been the development of human resources in health. As far as I’m concerned – and this is what I’ve learned from the Cuban experience – the

development of public health depends first and foremost on the amount and quality of people working in the sector. With too few people, or with people not fully trained and capable, providing proper health care proves impossible. In Cuba, we have worked hard to train comptent doctors, nurses, health technicians and social workers. And they are the mainstay of the health system.

MR: What do you think about progress - or lack of it - towards the UN Millennium Development Goals?

FRO: So far, the world has been unable to meet the objectives. We have the necessary technology, and we may have the necessary funds, but the political will isn’t there on a global scale. This includes the struggle to make poverty history, which should be our number one objective. Sometimes, looking at the percentages we say, ´Ah! Poverty has decreased by one or two percent.´ However, looking at absolute figures, we find that each year the number of poor people is higher. And this is due to the fact that the world population is growing. Therefore, despite one- or two-percent decreases, there are still a million more people in the world who are poor.

It’s like being on a treadmill – we’re walking a lot but getting nowhere. Or worse: we keep moving towards meeting our objectives for this millennium, but instead of making progress we’re moving backwards. We’ve set our target for 15 years and though one third of this time has already elapsed, we have not yet achieved one third of what we expected to. We are behind schedule. The culprits? Lack of political will from many countries, and the ever increasing power of neo-liberal policies.

To learn about Cuba and the MDGs, see Spotlight MDGs & Health Equity in Cuba .

INTERNATIONAL COOPERATION REPORT

Cuban Disaster Doctors in Guatemala, Pakistan

Volunteers for the Henry Reeve Brigade at the Havana ceremony constituting the volunteer disaster team.

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Now 3,000 strong, the team’s members are required to speak at least two languages, take post-graduate courses in epidemiology, and be physically fit. They also receive specialized training in medical assistance during epidemics and pandemics and HIV prevention methods and treatment for people suffering from HIV/AIDS.

“We’re ready and willing to go anywhere we’re needed,” said Dr. Dayane González, “whether it’s Cuba, the United States, wherever.” Dr. Gonzalez’ colleague and fellow team member Dr. Alexander Martínez echoed this sentiment when asked to which country he preferred to travel. “We’re trained to serve and help save lives; wherever that’s necessary, I’m willing to go.”

Henry Reeve Team In Action

And what a need there is: several hundred specialists are currently serving alongside local and other international health workers in post-earthquake Pakistan, and in Central America in the wake of Hurricanes Stan and Wilma. While each disaster scenario provides particular challenges, the circumstances in which the Henry Reeve Teams are working to save lives are both tragic and trying.

Guatemala, with over 840 missing and 650 dead following Hurricane Stan, was the first country to accept the Henry Reeve doctors, and 300 began arriving on October 8th., each carrying medicine-filled backpacks to treat acute diarrhea, respiratory illnesses, skin afflictions, malaria, dengue, and other illnesses. By the end of October, the Cuban Henry Reeve volunteers in Guatemala numbered 600.

Among their ranks are surgeons, pediatricians, internists, vector specialists and epidemiologists. These professionals supplement the 235 Cuban doctors on long-term stints in Guatemala, providing rural primary health care services as part of the ongoing Comprehensive Health Program (CHP). The CHP was established between Cuba and several Central American countries following Hurricane Mitch in 1998, as a more sustainable way to address these country’s underlying health problems.

Speaking from Guatemala, Dr. Yoandra Muro, head of the Cuban CHP team there said, “the situation is very difficult

and our main goal now is to prevent epidemics, which we have done, despite outbreaks.” The Cuban doctors have also been going house to house in a prevention campaign where they inquire about general health – particularly fevers and diarrhea - and talk to families about measures such as the need to boil drinking water. The strategy has paid off according to Muro, who believes basics like this have saved many lives, especially among children.

As new Cuban volunteers arrived in Guatemala on October 8, a 7.6 earthquake ripped across northern Pakistan, killing upwards of 73,000 people and seriously injuring another 69,000, according to Pakistan’s chief of disaster response. The death toll was predicted to rise as relief teams made their way into previously inaccessible areas.

As many as 3 million people were made instantly homeless – three times the number of Asia’s December tsunami - as the bitter winter approached. Relief officials announced recently that there are not enough winter-weather tents in the world to house these people. Into this situation arrived 200 Cuban doctors - including surgeons, anesthesiologists, internists and trauma specialists - one of the largest groups of foreign doctors to come to Pakistan’s aid.

Later planeloads of physicians have dramatically increased the original number, so that by press time, there were over 900 Cuban doctors serving in Pakistan. Further supplies pledged by Cuba to the Pakistan relief effort include three field hospitals and hundreds of winterized tents.

At this writing, the Cuban team is divided among three hospitals, one in central Islamabad, which is receiving patients airlifted to the capital for care. “We’re working very intensely in 12-hour shifts,” said one Cuban volunteer at the hospital. “It’s astonishing the number of children we’re treating, especially for trauma.” International Track Record

Cuban medical teams have been providing international di-saster aid for 45 years, beginning in 1960 when the 20th Century’s most violent earthquake struck Chile, killing 5,000. Since then, Cuba has provided post-disaster medical and technical assistance to nearly a dozen countries.

Recognition of Cuban expertise in disaster preparedness and response prompted the UN Development Program (UNDP) and Association of Caribbean States to select Havana as head-quarters for the new Cross Cultural Network for Disaster Risk Reduction to facilitate regional cooperation in disaster manage-ment (see MEDICC Review Vol. VII, No. 7, 2005).

Keeping a universal public health system with such interna-tional solidarity underpinnings such as Cuba’s well staffed in both quantity and quality is an ongoing challenge. On September 19th, in the same ceremony officially constituting the international disaster and epidemics team, Cuban medical schools graduated 1,905 new doctors from across the country.

Increased opportunities to study health science careers have also boosted enrollment. In the 2005-2006 academic year, 95,595 Cuban students are matriculated in medicine, nursing, dentistry, clinical psychology and university-level allied health sciences.

Who Was Henry Reeve?

Born on April 4, 1850 in Brooklyn, NY, Henry Reeve fought in the U.S. Civil War (where his abolitionist and anti-colonial sentiments crystallized), before landing in Cuba on May 11, 1869 to fight in the First War of Independence from Spain. According to Cuban history books, he distinguished himself for his bravery in 400 battles, eventually becoming a Brigadier General in the independence forces. On August 4, 1876, he was wounded by three enemy bullets, and as Spanish horsemen charged, he delivered the final, fatal shot himself rather than fall into enemy hands.


Abelardo Ramírez Márquez, MD, PhD Cándido López Pardo, PhD, MPH

HEALTH EQUITY: CONTEMPORARY APPROACHES

Perhaps the most widespread and well-summarized definition of health inequity is the one proposed by Margaret Whitehead, which in essence states that inequity refers to unnecessary and avoidable inequalities that are moreover, unfair. Thus, to describe a situation as inequitable, the cause must be examined and judged unfair in the context of what is happening in the rest of society.[1] Therefore, equality does not necessarily imply equity, just as inequality does not necessarily imply inequity. An unfair equality is likewise an inequity.

Gwatkin[2] identifies several periods in which health inequalities and other aspects of health status and services have been treated in different ways. One of these was in the early 70s, when the emphasis was on the improvement of poor people’s health, so they could obtain the same health benefits available to the most favored. Another was in the mid-80s, when, among other things, the capacity for primary health care to produce the expected benefits was placed in doubt, thus shifting interest from “health for all” to “health sector reform.” Then, in the mid- to late-90s, the focus returned to concern for the distribution of health and health services. Gwatkin predicted that interest would be renewed in aspects of distribution, due to the growing interest in poverty and inequality in global development and as a result of developments in global health.

Peter and Evans[3] present four philosophical-moral approaches to health equity. The utilitarian approach advocates the need to

maximize the sum of individual well-being, assuming that the capacity of all people to enjoy good health is equal. According to this framework, achievement of maximum health for the population implies that each person reaches the highest level of health, regardless of which groups are achieving these benefits (rich or poor), provided the benefits exert the same effect on the health of the entire population.

The egalitarian approach focuses on distribution without placing value on total health. There are different types of egalitarian theories; not all prioritizing health. For example, the “equal resources” approach states that only equal general resources - such as economic opportunity - are necessary and once such equality in resources is obtained, it simply depends on how each person wishes to use it. From this point of view, a society that guarantees its citizens equal resources does not need to give health care special attention.

The priority approach is considered a counterbalance to the utilitarian approach. It requires that health benefits be assigned to the most ill and emphasizes that differences in health outcomes are only of secondary importance, placing emphasis instead on final health outcomes. This perspective

focuses on those in the worst health and not necessarily on the health of the poorest.

The approach derived from the Rawlsian ideal of society as a fair, cooperative system, understands health inequalities as a consequence of a social organization that does not satisfy the requirements of fair social cooperation. Considered unfair are inequalities of class, gender, race, region or other determinants originating in a society’s basic structure and that may be the result of a social division of labor that benefits the more well-to-do at the expense of the most disadvantaged.

The debate over health equity reveals a diversity of definitions and approaches. The objectives of the proposal at hand demand - as we found in previous work[4] - an understanding that contemporary Cuban society is legitimated on the basis of social equity, and it is this equity approach that underpins its economic and social policies. The notion of equity we start from is based on social justice criteria that do not deny diversity, but instead regard it as a socially enriching element. This notion presupposes overcoming all discriminatory practices in every sphere of human activity. For us, health equity means equal opportunity to access available resources, a democratic distribution of power and knowledge in the health system, and health policy that benefits everyone without granting privileges due to differences in race, gender, territory, disability or any other distinguishing group or individual feature.

EXPERIENCES WITH HEALTH EQUITY MONITORING SYSTEMS

In the 90s, a good number of projects emerged related to poverty, equity and health, in which a number of countries

CUBAN PROFESSIONAL LITERATURE REVIEW ARTICLE

A Monitoring System for Health Equity in Cuba

ABSTRACT: This paper summarizes essential aspects of the doctoral thesis entitled “A Proposal for a Monitoring System for Health Equity in Cuba,” presented by Dr. Abelardo Ramírez Márquez, who was First Vice-Minister of the Ministry of Public Health at the time, for his PhD in Health Sciences. The objectives of the proposed system are: to identify the inequalities in health care – both in population health status and its determinants – by territorial and population groups, taking into account time factors, and to determine the association between population health status and health determinants. Additionally, this article assesses the health inequities resulting from the inequalities identified. The prevailing approaches to the concept of equity are discussed, particularly equity in the health field. The experiences of health equity monitoring systems in Latin America are presented and certain characteristics of the proposed monitoring system are described. Also considered is the rationale for such a system in Cuba, its coverage and units of analysis, plus the information and indicators to be monitored. Information collecting procedures; general and specific objectives of analysis; system users and outputs; the characteristics of a geographic information system; and the limitations of the system suggested, are also addressed. The system is expected to reveal realities concerning the population’s health situation and its invisible determinants and to produce results to inform decision-making at all levels of the National Health System.

Keywords: MONITORING; HEALTH INEQUALITIES; EQUITY; CUBA


were involved. These projects are particularly important for quantifying health inequalities, as a way of assessing health inequities. In a study for the World Bank, these projects were identified.[5] Some of them were related in one way or another to monitoring systems, which although similar in purpose, may differ substantially in their design. The present discussion is limited to certain Latin American experiences.

In Chile, continuous health care equity monitoring is car-ried out at regional and communal levels through routine collec-tion of demographic, vital statistics, socioeconomic, educational and morbidity and mortality data from different sources.[6] In Brazil, health inequalities are monitored at regional and state levels. The system is based on information from different sources and takes into account indicators of human resources, health care capacities, access and use of health services, financing, quality of medical care, health situation and living conditions.[7] In Peru, although not conceptualized as a monitoring system, an analysis of the extent of health inequity has been carried out. The assessment aims, among other goals, to carry out more profound research into the magnitude of inequity in the health status of Peruvians, to show the need to include this issue on the national agenda, involving not only the academic community, but also politicians, public officials and civil society in general.[8]

Other health equity studies, particularly with respect to ac-cess to health services and services of equal quality, were carried out in Colombia and Venezuela.[9] To learn of other experiences in health care equity monitoring, work carried out by the World Health Organization[10] and the Health Systems Trust [11] may be consulted; additional research may be referred to for more general conceptual and methodological aspects related to the measurement of health inequalities.[12-20]

CHARACTERISTICS OF THE PROPOSED HEALTH EQUITY MONITORING SYSTEM

Three elements justify the application of a health equity monitoring system in Cuba:

1. The substantive changes that have occurred in the living conditions of the population and other economic and social spheres, together with the reduction of the homogeneity that characterized the Cuban population.

2. We are still far from knowing how social disparities may affect population health status.a

3. Research is needed on diversity among human groups that are different in various ways, including in their ac-cess to health services, as well as their geographical and socioeconomic conditions.

Objectives of the proposed system:

1. Identify health inequalities - with respect to population health status as well as its determinants - among differ-ent territories and population groups, taking time factors into account.

2. Determine the existing association between the levels of population health status and health determinants.

3. Evaluate health inequities resulting from the inequalities identified.

The system is structured on the following bases:

• It should be coherent with national health policy and its specific strategies.

• It should be developed in accordance with existing resources.

• It should be sensitive to relatively short-term changes in population health status and health determinants.

• It should have enough flexibility to respond to users’ needs.

• It should complement and integrate available information produced by other agencies of the Ministry of Public Health and other bodies.

Expected results

The system is expected to:

1. Elucidate realities of the global health status that are not currently visible.

2. Identify elements for producing alerts, within the health and other sectors.

3. Produce useful results to inform political-administrative decision-making at different levels of the National Health System, depending on the magnitude and distribution of the event under consideration.

Coverage and units of assessment

The system’s coverage is national and the units of assess-ment are the country’s 169 municipalities.

Information to be monitored

The system will capture information of a permanent, as well as occasional, nature. Permanent information will flow according to certain procedures, while transmission of occasional information will be determined at the necessary time according to prevailing circumstances.

In terms of permanent information, the health status of the population will be monitored, as well as its determinants. The areas of population health status to be monitored are:

• Under-five child mortality;• Maternal mortality;• Mortality and morbidity from specific causes;• Nutritional status; and• Disability.

In relation to the determinants considered (medical care, social, economic, environmental and demographic),b the areas and indicators to be permanently monitored are shown in Appendix 1.

Indicators to be monitored

The process for selecting the indicators for the monitoring system began with the identification of potential indicators available from all municipalities in the country. These were submitted for consideration to a large group of experts from the health and other sectors to evaluate their inclusion in the monitoring system. The selected indicators associated with each area of population health status are listed in Appendix 2. The source of information for these indicators is the National Statistics Division of the Ministry of Public Health.

a From here on, population health status refers to mortality and morbidity levels and/or patterns. Global health status refers to both population health status and health determinants.

b There are multiple ways for defining health determinants. In the present paper, we used the one that seemed most appropriate for grouping the areas subject to monitoring.


Sixty-two experts from 17 institutions or agencies participated in the design of the system - particularly in the selection of the indicators; seven branches of the Ministry of Public Health also took part. Twenty-seven indicators linked to population health status and 52 linked to determinants were identified.

The indicators selected for monitoring related to each area of determinants are listed in Appendix 1. The information, except for some indicators, will be collected annually.

Additionally, as part of the permanent module, results from the Public Opinion Reporting System of the Health Tendencies Analysis Unit, will be considered. This system collects feedback from patients and service deliverers about health services, permitting assessment of the fundamental problems affecting satisfaction.

Data collection procedure

At system headquarters - proposed to be located at the Ministry of Public Health - data would be centrally processed from three sources: the system’s provincial headquarters, national agencies, and the national Health Tendencies Analysis Unit. Data flow is summarized in Figure 1.

Data Analysis Objectives Analysis of resulting information has the following general

objectives:

1. Identify existing gaps in the availability of resources and services in health and other sectors.

2. Monitor - in time and space - the mortality and incidence or prevalence (as appropriate) of the defined diseases and adverse effects on health.

3. Identify the extent and patterns of space-time distribu-tion of the areas under study related to population health status and the determinants.

4. Determine the association between levels of mortality, incidence or prevalence, and levels of the determinants studied.

5. Identify the potential impact on population health status or the determinants considered of interventions under-taken in time series dynamic.

6. Determine the efficiency of defined resources on the re-sults of population health status and the determinants.

7. Determine homogeneity of municipalities in achieving success in global health status.

8. Evaluate municipalities with respect to their global health status according to a synthetic index.

The 4th objective constitutes a key aspect of the system and conforms to the emphasis in recent years on the need to monitor the association between a population’s health status and its socio-economic status. This system proposes to extend monitoring of such associations to other elements of health determinants. The role played by social and economic determinants in population health status disparities is sufficiently supported, conceptually as well as empirically.[21-23] For example, Casas, Dachs and Bambas[23] document wide health differences - both in population health status and services - between those with high and low levels of well-being (whether measured by income or other material con-ditions); and among those registering differences in educational level, territorial distribution (for example, between geographical regions or urban and rural areas), ethnicity, gender, physical and financial access to health services and national origin.

Figure 2 illustrates specific assessment goals under each of the general objectives put forward, and the respective universes to be studied.

Geographic - Information System Design

Several Geographic Information Systems were analyzed for use in this system. The most convenient found was the SIG Epi version 1.0, designed by the Special Program for Health Analysis of PAHO, due to its accessibility, computer programming attributes, multi-layer data management, and use of different spatial analysis methodologies. The data assessment layers in this system propose analysis of each variable according to territorial - provincial and municipal - references.

Treatment of Information in Municipalities with Small Populations

Mortality and morbidity analysis performed in those municipalities with relatively small populations is always a concern when the frequency of an event considered is low and the population

Figure 1: Information Flow for the Health Care Equity Monitoring System


is very small, the rates vary widely and change notably in the same territory, by virtue of any slight change in the number of cases. The use of several methods that address this problem will be explored, among them the Bayesian model. Populations of Cuban municipalities range from 9,000 (Ciénaga de Zapata, pop. 9,037, est. June 30, 2002) to over 50 times that (Santiago de Cuba, pop. 479,475, est. June 30, 2002).[24]

System Outputs

The system will group permanent outputs for the most relevant information in tables, graphics and maps, their format designed to reflect the most relevant information. Additionally, the output module allows development of these same tools on an occasional basis as circumstances require.

System Users

System users will be management-level personnel in state, health and other sectors who require the information for their work. In principle, all institutions involved in providing information will be system users (see Figure 1). By the same token, political and civil organizations and the mass media will also be system users according to their needs. Permanent results will be published annually and occasional results will be published periodically as required. Information channels will be established in accordance with users’ characteristics.

Limitations of the System

Identification of the possible association between the levels and trends in population health status and health determinants is carried out in this system using an ecological approach, understanding that the unit for assessment is a conglomeration of individuals grouped according to geo-demographical, socioeconomic or other criteria.[25] This type of study frequently carries the potential risk of committing the common ecological error in assuming that associations found among groups are equally true for individuals. According to Susser,[26] Riley[27] uses the term aggregation fallacy to describe the error of applying associations identified among groups to individuals; and the term atomistic fallacy to describe the reverse, that is, inferring ecological relations among groups from observations carried at the individual level.

Nevertheless, concern for this fallacy may be exaggerated (constituting the fallacy of the ecological fallacy), because there may be no interest in extrapolating to individual levels what was found at the group level. Moreover, in many instances, it would make no sense to carry out an analysis at the individual level since the characteristics of the variables studied can only be interpreted at a group level. According to Silva[28] - who revives use of this approach - ecological studies have lost popularity in contemporary epidemiological research, partly due to the fear the ecological fallacy engenders and partly due to prejudices. Of these last, the most well established and pernicious is the conviction that the variables measured at group level do not represent causal agents of disease.

Specific goal Universe for study

1.1 Identify municipalities significantly deprived of resources and services. Municipalities as a whole, or groups of them

1.2 Identify inequalities in distribution of resources and services with respect to population distribution.

Municipalities as a whole, groups of them and each municipality in particular

1.3 Determine the proportion and number of resources and services that would need to be redistributed among municipalities or groups of municipalities to achieve equity in their distribution, defined by specific criteria.

Municipalities as a whole or groups of them

1.4 Identify spatial clusters of municipalities with notoriously low numbers of available resources and services. Same as above

1.5 Evaluate trends and forecast availability of resources and services.Municipalities as a whole, groups of them and each municipality in particular

1.6 Identify if interventions have modified the availability of resources and services over time. Same as above

1.7 Determine the lag between time of intervention and the most significant moment of the impact, if there is a change in the trend of the time series. Same as above

2.1 Detect significant increases over time in morbidity and mortality for diseases and adverse health effects considered. Same as above

2.2 Identify municipalities with a significant excess of mortality or morbidity of diseases and adverse health effects, for each defined category of determinant indicators.


2.3 Identify the existence of significant interaction between places and times of appearance of disease and other defined health problems.


3.1 Determine the mortality and morbidity of diseases or adverse health effects and their association with defined factors. Same as above

3.2 Identify inequalities in mortality and morbidity according to population distribution. Same as above

3.3 Identify spatial clusters of municipalities with outstanding high or low mortality and morbidity indicators.


3.4 Determine mortality and morbidity time clustering. Municipalities as a whole, groups of them and each municipality in particular

3.5 Evaluate trends and forecast mortality and morbidity levels. Same as above

Figure 2: Goals & Universes to be Studied


3.6 Identify seasonal patterns of mortality and morbidity. Same as above

4.1 Identify existing association between mortality and morbidity levels and categories of determinants. Same as above

4.2 Determine the difference in mortality and morbidity levels between the stratum with the best determinants and other strata.

Municipalities grouped in strata, with respect to determinant’s indicator being considered

4.3 Determine average change in mortality or morbidity indicator for every unit change in determinant indicator. Same as above

4.4 Determine relative variations in average changes in mortality or morbidity indicator in successive intervals of given determinant indicators. Same as above

4.5 Evaluate proportional and absolute changes in global mortality or morbidity levels if all strata possessed the best determinant condition. Same as above

4.6 Evaluate proportional and absolute change in mortality or morbidity levels of each stratum if they all possessed the best determinant condition. Same as above

4.7Evaluate relative risks in mortality or morbidity for each stratum with respect to the stratum with the best determinant condition adjusting for factors that may cloud the effect of variables considered.

Same as above

4.8 Determine the extent of difference in mortality or morbidity considering inequalities in a certain determinant area.


5.1 Identify if there has been a significant change in the dynamics of the time series near the moment when interventions took place. Same as above

5.2 Determine the delay between the moment of intervention and the instant of greatest impact, if there was a change. Same as above

6.1 Identify those municipalities that achieved results in population health status higher or lower than expected according to availability of resources.


6.2 Identify municipalities that achieved results in aspects of determinants that were higher or lower than expected according to existing resources. Same as above

7.1 Identify municipalities with different balances in health outcome levels. Same as above

7.2 Rank municipalities according to levels of homogeneity in achieving health outcomes. Same as above

8.1 Determine the global health status for each municipality in relation to a group or all of the municipalities using a territorial indicator of health equity (TIHE). Same as above

8.2 Identify gaps in global health status between different municipalities. Same as above

8.3 Rank municipalities according to their degree of development in global health. Same as above

8.4 Determine if there are spatial clusters of municipalities with significantly low or high values of TIHE. Same as above

8.5 Determine the efficiency of each municipality in achieving its global health situationas a function of available resources. Same as above

Additionally, as Kunst and Mackenbach[29] point out, the value of ecological studies lies in that they can indicate the effect of socioeconomic inequalities on health when there is no information available at the individual level. Moreover, these authors note, the comparison between areas may provide highly relevant information for local policies, since they clearly identify areas with excessive health problems.

CONCLUSIONS

A health care equity monitoring system is justified in Cuba because of the substantive changes that have occurred in the living conditions of the population and other economic and social spheres, together with the reduction of the homogeneity that characterized the Cuban population; because we are still far from knowing how social disparities may affect population

health status; and because research is needed on diversity among human groups that are different in various ways, includ-ing their access to health services, as well as their geographical and socioeconomic conditions. There is also the political will of the Cuban government to eliminate unjust inequalities that may exist in the country.

Implementation of the system is feasible thanks to the availability of the information required and because the inherent procedures have been designed.

An evident need exists for an inter- and trans-disciplinary approach to design a monitoring system that would allow the identification of health inequalities using an integral approach that includes the health status of the population and its deter-minants.


RECOMMENDATIONS

• The leadership of the Ministry of Public Health should evaluate the proposed health care equity monitoring system for its application.

• The experiences of this study should be taken into ac-count in future monitoring system designs for health or other sectors, related to population health status and/or its determinants.

• Those interested in analysis of territorial development should take into account this work and are encouraged to design other monitoring systems at the local level.

• Health sector specialists should become familiar with the conceptual aspects considered in this paper, with which in general, there is not sufficient familiarity.

• The National School of Public Health, the Higher Institutes and Schools of Medicine and other academic institutions in health and other sectors should consider incorporating the contents of this paper in their curricula.

REFERENCES

1. Whitehead M. The concepts and principles of equity. Copenhagen: World Health Organization; 1991.

2. Gwatkin DR. Reducing health inequalities in developing countries. In: Background Reading, International Meeting "Equity Gauge: an approach to monitoring equity in health and health care in developing countries." South Africa, 17-20 August 2000.

3. Peter F, Evans T. Dimensiones éticas de la equidad en salud. In: Evans T, Margaret W, Diderichsen F, Bhuiya A, Wirth M, eds. Desafío a la falta de equidad en salud: de la ética a la acción, Was-hington, DC: Fundación Rockefeller; Organización Panamericana de la Salud; 2002. (Publicación Científica y Técnica No. 585).

4. Escuela Nacional de Salud Pública. Proyecto “Monitoreo de Equidad y Salud en Cuba.” Grupo Básico de Trabajo. La Habana; 2001. (Mimeo).

5. Carr D, Gwatkin DR, Fragueiro D. Multi-country study programs on equity, poverty and health. s/l: World Bank; 1999. (Mimeo).

6. Vega J. Disentangling the pathways to health inequities: the Chilean health care equity gauge. Pontificia Universidad Católica de Chile; 2002. (Mimeo).

7. Nunes A. Medindo as desigualdades em saúde no Brasil: uma proposta de monitoramento. Brasilia: Organización Panamericana de la Salud; 2001.

8. Valdivia M. Acerca de la magnitud de la inequidad en salud en el Perú. Lima: Grupo de Análisis para el Desarrollo; 2002. (Docu-mento de Trabajo 37).

9. Málaga H. Equidad en materia de salud y oportunidad de vida en Venezuela y Colombia. In: Pan American Health Organization. Equity & health; views from the Pan American Sanitary Bureau. Washington, DC: Pan American Health Organization; 2001.(Occasional Publication No.8).

10. World Health Organization. Final report of meeting on policy-oriented monitoring of equity in health and health care, Geneva, 29 September-3 October 1997. Geneva: World Health Organization;1998. (Document WHO/ARA/98:2).

11. Health Systems Trust. Project summaries. International meeting "Equity Gauge: an approach to monitoring equity in health and health care in developing countries." South Africa, 17-20 August 2000. (Mimeo).

12. Whitehead M, Scott-Samuel A, Dahlgren G. “Setting targets to address inequalities in health.” Lancet 1998; 351:1279-82.

13. Borrell C. La medición de las desigualdades en salud. Gac Sanit 2000;14 (supl.3):20-33.

14. Murray CJL, Gakidou EE, Frenk J. Health inequalities and social group differences: what should be measured. Bull World Health Organ 1999; 77:537-42.

15. Programa Especial de Análisis de Salud de la Organización Panamericana de la Salud. Indicadores/metodologías para me-

dir/establecer equidad en salud. Elaborado para la Reunión de Gerentes de OPS. Washington DC, 1999.

16. Anand S. Medición de las disparidades en salud: métodos e indica-dores. In: Evans T, Margaret W, Diderichsen F, Bhuiya A, Wirth M, eds. Desafío a la falta de equidad en salud: de la ética a la acción. Washington, DC: Fundación Rockefeller; Organización Panamericana de la Salud; 2002. (Publicación Científica y Técnica No. 585).

17. Dachs N. Inequidades en salud: cómo estudiarlas. In: Restrepo H, Málaga H. Promoción de la salud: cómo construir vida saludable. Bogota: Editorial Médica Panamericana; 2001.

18. Sen A. Many faces of gender inequality. Inauguration lecture for the New Radcliffe Institute at Harvard University. April, 2001. The New Republic, September 17, 2001.

19. Wolfson M, Rowe G. On measuring inequalities in health. Bull World Health Organ 2001; 79:553-60.

20. Kunst AE, Mackenbach JP. Measuring socioeconomic inequalities in health. Copenhagen: World Health Organization, Regional Office for Europe; s/f. (Document EUR/ICP/RPD 416).

21. Castellanos PL. Proyecto: Sistemas Nacionales de Vigilancia de Situación de Salud según Condiciones de Vida y del impacto de las Acciones de Salud y Bienestar. Washington DC: OPS/OMS; 1991.

22. Braveman P. Monitoring equity in health: a policy oriented approach in low-and-middle income countries. Geneva: WHO; 1998. (Doc. WHO/CHS/HSS/98.1).

23. Casas JA, Dachs N, Bambas A. Health disparities in Latin America and the Caribbean: the role of social and economic determinants. In: Equity and health: views from the Pan American Sanitary Bureau. Washington DC: PAHO; 2001. (Occasional Publication No. 8).

24. Oficina Nacional de Estadísticas (ONE). Anuario estadístico de Cuba 2002; edición 2003. La Habana: ONE; 2003. Tabla II, 5: 66-69.

25. Schneider MC. Métodos de medición de las desigualdades en salud. Rev Panam Salud Pública 2002;12:398-414.

26. Susser M. Causal thinking in the health sciences: concepts and strategies of epidemiology. New York: Oxford University Press; 1973. p.60.

27. Riley MW. Sociological research. Vol.1. New York: Harcourt, Brace, Jovanich; 1963. p. 700-738.

28. Silva LC. Cultura estadística e investigación en el campo de la salud; una mirada crítica. Madrid: Editorial Díaz de Santos; 1996. p. 177.

29. Kunst AE, Mackenbach JP. Measuring socioeconomic inequalities in health. Copenhagen: WHO, Regional Office for Europe; s/f p.32. (Doc. EUR/ICP/RPD 416).

This paper was originally published in the Cuban journal Revista Cubana de Salud Publica, 31; 2: April-June, 2005. Reprinted by permission.

Acknowledgments

We thank Drs. Miguel Márquez and Francisco Rojas Ochoa for their collaboration in this paper, with regard to the project’s precursor in the proposal of Health Situation Surveillance System According to Living Conditions and a Project for Monitoring Equity and Health in Cuba proposed in the nineties. We also acknowledge the working group composed of Dr. Guillermo Mesa Ridel, Maritza Cedeño, BS, and Iraida Rodríguez, BS, later joined by Drs. Eduardo Zacca, Daniel Rodríguez Milord, Roberto González, Radamés Borroto and Pastor Castell-Florit. We are also grateful to Roberto González, BS, for his contribution to the design of a Geographically- Ref-erenced Information System and Drs. María del Carmen Pria and Giselle Coutin, Angela Tuero, BS and Ana María Clúa, BS for their contributions to the section on the treatment of information in municipalities with small populations.

THE AUTHORS

Abelardo Ramírez Márquez, 2nd Degree Specialist in Health Organization and Management, was a professor at the Havana Higher Institute of Medical Sciences and the National School for Public Health. (Deceased)Cándido M. López Pardo, Doctor of Health Sciences, Full Professor at the School of Economics, University of Havana; Visiting Professor, National School of Public Health.


Appendix 1: Indicators to be Monitored According to Determinant Area

Area Indicator Source

Health resources

Per capita health expenditure assigned to polyclinics, and hygiene and epidemiology centers (total of both) Number of family doctors in the community per 1,000 inhabitants Shortage of family doctor and nurse offices per 100 inhabitants Number of nurses in primary care (except those in childcare centers, work places and schools) per 100 inhabitants Number of dentists per 100 inhabitants Number of dental chairs per 100 inhabitants

PHD

Percentile 75 of the number of persons treated at the family doctor and nurse office MPH/DS

Shortage of basic medicines in the main municipal pharmacy (%) PPOS

Health servicesNumber of cases seen (total, in office and house calls), by family doctor per 1,000 inhabitants Home hospitalizations per 100 inhabitants

PHD

Social policy

Number of places in homes for the elderly, seniors’ day homes, or semi-boarding services per 100 inhabitants for persons 60 years or older Number of the following services rendered per 100 disabled persons according to type of disability:Type of Disability/Service providedDeafness/Hearing aidPhysical-motor/None Lower limb prosthesis/Wheelchair Mastectomy/Breast prosthesisPercentage of elderly adults (60 years or older) in fragile condition (total and by sex) Percentage of fragile elderly adults treated (total and by sex)

MPH/NDCE

Economic resourcesMunicipal budget per capita PDEP

Mercantile production per capitaTotal physically executed investment POS

Work force Relation of dependency POS

Resources for education Secondary school student/teacher ratioPercentage of students in primary schools with classrooms of 20 students or fewer PDE

Educational level of the population

Educational level of population under 14 years (global and by age groups: 6-11 year olds, 12-14 year olds)

PDE

Access to energy Percentage of houses with electricity POS

Housing conditionsPercent of houses according to technical conditions Percent of houses according to type of rooms Percent of houses according to type of construction

PHOD

Access to drinking-water Volume (m3) of water per inhabitant Average time (hours/day) of water service PDAS

Access to sanitation Percentage of population with access to a sewage system Percentage of population using septic tanks and latrines PDAS

Sports activity Number of persons systematically practicing sports per 100 inhabitants (global and by sex) PSD

Transportation Number of transportation means per inhabitant PTD

Communications Telephone lines per 100 inhabitants ETECSA

Resources for cultureNumber of inhabitants per public library

DPCNumber of inhabitants per community cultural center

Access to culture Number of total activities in community cultural centers per 100,000 inhabitants


Appendix 2: Indicators of Health Status

Area Indicator

Under 5 mortality Under 5mortality rate (global and by sex)

Maternal mortality Number of maternal deaths (total, direct and indirect)

Mortality and morbidity due to specific causes

Global mortality rate, by sex and age, adjusted mortality rate and years of potential life lost due to the following causes:Communicable diseases Bronchial pneumonia and pneumonia < 5, = 60 Acute diarrhea < 5,≥ 60Chronic diseases and adverse health effects Malignant breast tumor 25-39, 40-59, ≥ 60Malignant uterine tumor 25-39, 40-59, ≥ 60Malignant lung tumor 25-39, 40-59, ≥ 60Malignant prostate tumor 40-59, ≥ 60Malignant ileus and colon tumor 25-39, 40-59, ≥ 60Ischemic cardiopathy 25-39, 40-59, ≥ 60Traffic accidents < 5, 5-14, 15-24, 25-34, 35-44, 45-59, ≥ 60Home accidents < 1, 1-4, 5-14, 15-49, 50-59, ≥ 60Intentionally self-inflicted wounds 15-24, 25-39, 40-59, ≥ 60Assaults 15-24, 25-39, 40-59, ≥ 60Asthma < 15, 15-24, 25-39, 40-59, ≥60Alcoholic cirrhosis 40-59, ≥ 60Hip fracture ≥ 60Incidence or prevalence rate by sex and age of the following:Communicable diseases HIV-AIDS 15-40Acute diarrhea illnesses < 5 ≥ 60Lung tuberculosis 15-59, ≥ 60Gonorrhea 15-40Syphilis 15-40Scabies < 15Pediculosis < 15Chronic diseases and adverse health effects Intentionally self-inflicted wounds 15-24, 25-39, 40-59, ≥ 60

Nutritional status Low birth weightDisability Number of disabled persons per 1,000 inhabitants (total and by sex)

Source: National Statistics Division, Ministry of Public Health

Legend: Abbreviations

PHD: Provincial Health DepartmentMPH: Ministry of Public HealthSD: Statistics DivisionPPOS: Provincial Pharmacy and Optical ServicesNDCE: National Department of Care for the ElderlyPDEP: Provincial Department of Economics and Planning

POS: Provincial Office of StatisticsPHOD: Provincial Housing DepartmentPDAS: Provincial Department of Aqueducts and SeweragePSD: Provincial Sports DepartmentPTD: Provincial Transportation DepartmentETECSA: Cuban Telephone CompanyPCD: Provincial Culture DepartmentPDCS: Provincial Department of Community Services

Migration Net internal migration rate Net external migration rate

POSMarriage and divorce Divorce-marriage ratio

Urbanization Percentage urban population

Nutrition

Percentage of malnourished children under 1 year old Percentage of malnourished children from 1 to 4 years old Percentage of children under 1 year old at risk for malnourishment Percentage of pregnant women underweight at beginning of pregnancy Percentage of pregnant women with anemia in third trimester of pregnancy Percentage of elderly adults with chronic calorie deficiency

PHD

Environment Percentage of population with garbage collection services PDCS

Birth rate and population

Global fertility rate Early fertility rate (15-19 year olds) Percentage of population 60 years or olderPopulation density

POS


Cándido López Pardo, PhD, MPH Miguel Márquez, MD, MPH Francisco Rojas Ochoa, MD, PhD, MPH

CONCEPTS

The methodologies and results presented in this paper are constructed on the basis of concepts of human development and equity.

Although the concept of “human development” – basically development for human beings – had been previously considered, this concept gains momentum with the appearance of the first Report on Human Development prepared for the United Nations Development Program (UNDP) in 1990.

Human development is understood as the process by which human opportunities are expanded. In principle, these opportunities can be infinite and change over time; however, at all levels of development, the three most essential are – according to the UNDP[1] - enjoyment of a long and healthy life, acquisition of knowledge, and access to the resources required for a decent standard of living. According to this paradigm, development is not limited to fulfillment of income or production goals, nor does it consider people as mere beneficiaries of social welfare. Rather, human beings become the engine, and at the same time, the object of development. And thus, attributed to them is the possibility and necessity of active participation in the process of extending their own opportunities in different areas such as income, knowledge, a long life, freedom, individual security, community participation and the enjoyment of fundamental rights.

Without doubt, the concept of human development has positive aspects: it integrates and complements previous understandings where economic growth acquires a relative value in its association with development, and gives priority to social policies. Moreover, it has evolved from the thinking in which economic growth was considered a means, while development an end, to a concept where human development is considered both an end and a means. It is considered an end, due to its relation to economic growth,[2] and a means, because of its contribution to the increase of human capital to advance material prosperity.[3] However, it must not be forgotten – as Martínez states[4] - that the concept of human development applied to all countries cannot substitute for specific meanings and problems to be solved in countries with different levels of development, given the different connotation development has for countries which have achieved it and those still struggling to do so.

“Equity” – one of the dimensions of human development[5] - is a somewhat more complex concept, as consequently is “inequity.” Perhaps the most widely used and synthetic definition of health inequity - although valid as well for other

spheres - is that proposed by Margaret Whitehead, in essence stating that inequity refers to unnecessary and avoidable inequalities that, moreover, are considered unjust. Thus, to describe a situation as inequitable, the cause must be examined and judged as unjust in the context of what is occurring in the rest of society.[6] Therefore, inequalities are measured, and inequities are judged. However, the conceptualization of inequity cannot only be limited to inequalities; there are unjust, unnecessary and avoidable equalities that also should be considered inequities.

Methodologies proposed here are based on two additional concepts, which are “effectiveness” and “efficiency.” We understand by effectiveness, the capacity to achieve objectives and by efficiency, the relation between results and resources.[7]

METHODS

The Human Development Index

Probably the most noteworthy antecedent of the wide range of indices that have appeared in recent years to measure human development globally, or some of its aspects, is the Physical Quality of Life Index proposed by Morris,[8] which combined the indicators of infant mortality, life expectancy at one year and literacy. Presently, the arsenal available to quantify comprehensive human development or some of its dimensions – although it may not be conceivable that human development or specific aspects of human development are measured – comprises several dozen indices.

The “star” index of the Human Development Reports prepared for UNDP to quantify human development is the Human Development Index (HDI) introduced in the first report on human development in 1990,[9] which has been modified in successive annual reports since then. According to the writers of the Reports, the index measures human development comprehensively by considering the dimensions of longevity, knowledge acquired and income. It is considered “a measure of the capacity of people to achieve long and healthy lives, communicate and participate in the activities of the community and have enough resources to attain a reasonable standard of living.”[10] Each of the dimensions included in the HDI have been measured according to indices based on indicators that have not always been the same each time the index has been calculated.

Various critical reflections on the HDI have centered on its conceptual aspect - such as those by Breilh[11] and by Martínez[12]; its design, like that by Sunkel and Zulueta[13] with respect to the use of life expectancy at birth; as well as its procedures for considering income, critiqued, among others, by Lüchters and Menhkoff,[14] Anand and Sen,[15] the Cuban Cen-ter for Research on the World Economy (CIEM),[16] López,[17] and Silva.[18]

CUBAN PROFESSIONAL LITERATURE - REVIEW ARTICLE

Human Development and Equity in Latin America and the Caribbean


Other Indices Proposed

Several authors have proposed alternative synthetic indices to measure human development on a country scale, among them: Boltvinik,[19] Castellanos,[20] del Valle,[21] López,[22] Noorbakhsh,[23] and Lemos and Frías,[24] as well as on a territorial scale within a country.[24,25,26,27] Other researchers[28] recommend diversity of the socioeconomic niche as a measure of development, defining the “socioeconomic niche” as “the function, in its double condition of producer and consumer, carried out by each large group of persons with similar socioeconomic activity and purchasing power.” They mention the Shannon-Wiener and Simpson indices as measures of diversity.

As has been clearly expressed,[29,30] the relative position of one country’s human development in comparison with another’s is not unequivocal, but rather depends on the conceptualization of human development used and the way this human development is measured, definitions not necessarily devoid of the intentions of those applying them.

Human Development and Equity Index López[31] has suggested the Human Development and

Equity Index (HDEI) as an indicator of effectiveness in the achievement of human development. Introduced in the Study on Human Development and Equity in Cuba, 1999,[32] the index is made up of 11 indicators associated with three components: achievement in relevant areas of human development, equity of human groups inside the country, and the impact of income on human development (Diagram 1). A new application of this index was made in 23 countries in the region for the purposes of the current analysis of human development in Latin America and the Caribbean (LAC).

The HDEI includes the dimensions considered by the HDI

(economic development, educational level, and state of health) and includes other equally relevant dimensions of human development not taken into account in the HDI.

For a particular country and for each indicator, the relative achievement (RA) is obtained using the expression

RA = (Xcountry – min X) / (max X – min X),if a high value of the indicator is desirable (all those involved, except the student teacher ratio in primary education); or by the relation

RA = (max X – Xcountry) / (max X – min X),if a low value of the indicator is desirable, where Xcountry is the value of the indicator registered for the country, and min X and max X are the minimum and maximum observed in the group of countries.

The HDEI takes the following formHDEI = W1C1 + W2C2 + W3C3

where C1 and C2 are the average of the relative achievements for indicators of the first and the second components–indicators (1) through (8) and (9) and (10) respectively; and C3 is the achievement for indicator (11). W1, W2, and W3 are pondered values for each of the components. To establish these weights, it was understood that the first component (associated with the achievement of rel-evant aspects of human development) in which aspects of equity are, likewise, implicitly considered and to which a higher number of indicators contribute compared to the other two components, should have double the weight of the sum of the remaining two components. Each of these two components, which are related to equity of human groups inside the countries and the effect of income on human development, in turn, have a weight proportional to the number of indicators that are included in them.[33]

Thus, the index is obtained from the expressionHDEI = 2/3 C1 + 2/9 C2 + 1/9 C3

In this way, the HDEI may have values in the interval from 0 to 1; higher when relative human development - associated with eq-uity - is higher, in the universe of countries under consideration.

The use of the indicators (9), (10) and (11) deserves certain explanation. To measure the equity of human groups inside countries, in the Study on Human Development and Equity in Cuba 1999,[34] the indicators Absolute Parity and Pondered Parity were introduced. These indicators quantify the disparity in achieving aspects of hu-man development among defined groups. Absolute Parity measures how many times greater is the achievement in an aspect of human development in a group 1 with respect to a group 2, in this case, the

Diagram 1: Components, Dimensions and Indicators Included in the Human Development and Equity Index

COMPONENTS DIMENSIONS INDICATORS

Achievement in Relevant Areas of Development

Economic developmentEducational levelPopulation health statusAccess to basic services Access to culture and communicationResources and services for education

Resources and services for healthPreservation of the environment

(1) GDP per capita (PPP US$) (2) Adult literacy rate(3) Life expectancy adjusted to health(4) Percent of population with access to safe drinking water (5) Television sets (per 1000 pop.)(6) Student-teacher ratio in primary education

(7) Medical doctors (per 10000 pop.)(8) Annual average percent of change in forest surface

Equity of Human Groups Inside the Country

Gender equity(9) Woman-man pondered parity for the adult literacy rate(10) Difference in the country’s position with respect to HDI and GDI

Impact of Income on Human Development

(11) Difference in the country’s position with respect to its real per capita GDP and its GDI


adult literacy rate achieved by women and by men. However, that parity may be good, possibly equal to 100%, and yet the rates for both groups may be relatively low with respect to a better possible value. That is why the Pondered Parity confers on Absolute Parity a weight according to the relative success attained by the country in the aspect taken into consideration, measured by the Coefficient of Success. The different position of a country with respect to HDI and GDI (Gender-related Development Index) values (the first minus the second) shows the positive or negative impact of gender inequality in human development. At the same time, a positive difference in the location of a country with respect to its GDP per capita (PPP US$) and to its GDI, shows the country has achieved a better level of human development, considering the gender difference in human development, than the level obtained by its income.

The Index of Dissimilarity

The Index of Dissimilarity measures what percentage, or what absolute number of cases, must be redistributed to achieve the same rate in all socioeconomic groups or any other grouping under observation. The greater the inequality of the particular event among the groups considered, the higher the index value. Although it is used to redistribute cases of a disease, as has been stated,[35] its application is questionable in analyzing inequalities in mortality or morbidity, because there is no practical and ethical sense in redistributing deaths or diseases.

The Lorenz Curve and the Gini Coefficient

The Lorenz Curve permits inequalities to be identified in the distribution of a certain event according to population distribution, and to contrast this with the uniform or equal distribution represented by a diagonal line from the lower left to the upper right corner of the figure. When applied, as will be seen later, the curve represents the accumulated population percentages on the X axis and the accumulated percentages of the chosen variable on the Y axis; the larger the area found between the Lorenz Curve and the line of equality, the greater inequality in distribution. When the studied variable is “posi-tive,” let us say the number of inhabitants per physician, the curve is located under the line of equality. When the variable is “negative,” such as mortality due to a defined cause, the curve is located above the diagonal. The Gini Coefficient value corresponds to twice the area between the Lorenz Curve and the diagonal line. Gini Coefficient values may range from 0 to 1; higher when the inequality is greater. Those interested in studying these aspects more deeply may consult the work of Schneider et al.[35], among others.

The Homogeneity of Achievement Index

The calculation of this index (HAI) permits measurement of the degree of internal homogeneity within each country in the achievement of a defined group of indicators. The values of this index range between 0 and 1; higher, when the homogeneity or balance is greater.

The Relative Efficiency Index

The Relative Efficiency Index (REI) was included by López to quantify efficiency in the achievement of human development as a function of economic resources in LAC countries.[36] In

general, there is a results variable Y and a resource variable X. The procedure for calculating the index is summarized in the following stages:

1. Obtain the equation for adjustment of the results indica-tor as a function of the resource indicator.

2. Calculate the DISTANCE for each unit of analysis - countries, for example - being

DISTANCE = y - ŷ if a high value for the indicator is desirable,DISTANCE = ŷ - y if a low value for the indicator is desirable,

where y is the observed value for the results indicator and ŷ is the value of this indicator expected from the calcu-lated adjustment function.

INDICATOR SOURCE (a) REFERENCE

YEAR (b)

GDP per capita (PPP US$)

UNDP 2004, table 1 2002

Adult literacy rate (%)

PAHO 2003 2003

Healthy life expectancy

WHO 2004, table 4 2002

% population with access to safe drinking water

PAHO 2003 1998

Television sets (per 1000 inhabitants)

UNDP 2000, table 12 lya 1996-98

Student-teacher ratio in primary education

ECLAC 2004, table 36 2002 or cy

Physicians (per 10,000 inhabitants)

PAHO 2003 c 2000

Annual average percent change in forest surface

FAO 2004 1990-2000

Literacy rate for women (%)

PAHO 2003 2003

Literacy rate for men (%)

PAHO 2003 2003

HDI ranking UNDP 2004, table 1 2002

GDI ranking UNDP 2004, table 24 c 2002

GDP per capita (PPP US$) ranking

UNDP 2004, table 1 2002

(a) Sources:

ECLAC. Statistical Yearbook for Latin America and the Caribbean 2003. [on line] <http://www.eclac.org> [Viewed: 24/07/04]FAO. Country information [on line] <http://www.fao.org/forestry >[Viewed: 26/07/04]PAHO. Health situation in the Americas; basic indicators 2003. Washington DC: OPS; 2003. (Doc. OPS/AIS/03.01)UNDP. Informe sobre desarrollo humano 2000. Madrid: Ediciones Mundi Prensa; 2000.UNDP. Human Development Report 2004 [on line] <http://www.undp.org> [Viewed: 24/07/04] WHO. The world health report 2004 [on line] <http://www.who.int/en> [Viewed: 25/07/04]

(b)Legend: lya-last year available in period. cy-closest year.

Table 1: Sources and Reference Years of the Indicators Considered for the HDEI


Table 2: Values of Basic Indicators Considered in the HDEI

COUNTRY GDP LITER HALE WATER TV

Argentina 10880 97.1 65.3 78.6 289

Bolivia 2460 87.1 54.4 73.5 115

Brazil 7770 88.1 59.8 89.0 316

Chile 9820 96.2 67.3 94.2 232

Colombia 6370 92.4 62.0 90.6 217

Costa Rica 8840 96.0 67.2 95.0 387

Cuba 5259 97.0 68.3 92.9 239

Dominican Rep. 6640 84.7 59.6 87.6 84

Ecuador 3580 92.4 61.9 70.3 293

El Salvador 4890 80.2 59.7 59.4 250

Guatemala 4080 70.5 57.4 80.3 126

Guyana 4260 98.8 55.2 92.9 59

Haiti 1610 52.8 43.8 46.0 5

Honduras 2600 76.8 58.4 80.9 90

Jamaica 3980 88.0 65.1 80.5 323

Mexico 8970 92.0 65.4 86.5 261

Nicaragua 2470 67.5 61.4 66.5 190

Panama 6170 92.6 68.2 86.9 187

Paraguay 4610 93.9 61.9 43.6 101

Peru 5010 90.9 61.0 75.4 144

Trinidad-Tobago 9430 93.9 62.0 86.0 331

Uruguay 7830 97.8 66.2 97.8 242

Venezuela 5380 93.4 64.2 83.1 185

ST-TEACH PHYSIC FORESTLIT/

WOMENLIT/MEN

17 30.4 -0.8 97.0 97.0

25 3.3 -0.3 80.7 93.1

22 20.6 -0.5 86.5 86.2

32 11.5 -0.1 95.6 95.8

27 9.4 -0.4 92.2 92.1

23 12.7 -0.8 95.9 95.7

9 59.6 1.3 96.8 97.0

32 19.0 0.0 84.4 84.3

23 14.5 -1.2 89.7 92.3

53 12.6 -4.6 77.1 82.4

34 10.9 -1.7 62.5 77.3

29 2.6 -0.3 98.2 99.0

30 2.5 -5.7 50.0 53.8

34 8.7 -1.0 80.2 79.8

31 8.5 -1.5 91.4 83.8

27 15.6 -1.1 88.7 92.6

39 6.2 -3.0 76.6 76.8

21 12.1 -1.6 91.7 92.9

24 4.9 -0.5 90.2 93.1

24 10.3 -0.4 80.3 91.3

26 7.5 -0.8 97.9 99.0

21 38.7 5.0 98.1 97.8

20 20.0 -0.4 92.7 93.5

3. Calculate the index using the expressionREI = DISTANCE / DISTANCEMAXIMUM POSITIVE if the DISTANCE is positive; and byREI = - ( | DISTANCE | / | DISTANCEMAXIMUM NEGATIVE | ) if the DISTANCE is negative.

The REI may adopt values between -1 and 1, the first value indicating the highest negative relative efficiency (or the highest relative inefficiency) and 1, the highest positive relative efficiency.

RESULTS

The HDEI was calculated for the 23 LAC countries with a population of 500,000 or more[37], excluding those with a small critical mass of information. Table 1 shows the sources and reference years for the indicators used in the index. A single information source from a national institution was never used for any of the countries to avoid biases in the information.

The values of the indicators considered in the index are shown in Table 2.

This data reveals the existence of extraordinary inequali-ties among countries in the region. While some have a GDP per

capita (PPP US$) close to or over 10,000 annually, there are others for which this figure reaches only a third of this sum. There are countries where practically all the population is literate; while in others, only 2 out of every 3 persons, or even fewer, can read and write.

There are countries in which almost all the population has sustainable access to drinking water; in others, not even half the population has access to this basic service. UNICEF considers lack of drinking water and sanitation one of the most important dividing lines between those living under conditions of absolute poverty and the rest of humanity.[38]

Such abysmal differences in key aspects of health determi-nants implies that relatively close countries differ substantially in their life expectancies. A person born in Haiti, Bolivia or in Guate-mala, for example, is expected to live 10 or more years fewer than a person born in Cuba, Chile or Costa Rica.

The Index of Dissimilarity reveals that to attain eq-uitable distribution, according to the underlying population, 4% of the total of persons with access to drinking water and some 160,000 physicians (about 17%) would have to be redis-tributed.

GDP: GDP per capita (PPP US$)LITER: Adult literacy rate (%)HALE: Healthy life expectancyWATER: % of population with access to safe drinking waterTV: Television sets (per 1000 inhabitants)

ST-TEACH: Student-teacher ratio in primary educationPHYSIC: Physicians (per 10,000 inhabitants)FOREST: Annual average % change in forest surfaceLIT/WOMEN: Literacy rate, women (%)LIT/MEN: Literacy rate, men (%)


Figure 1 shows the distribution of physicians per population in the region. Among other results, it can be observed that 50% of the population has access to only a bit over 10% of the available doctors.

On the other hand, not all countries show the same ho-mogeneity in the achievements of the diverse aspects of human development considered. While countries like Uruguay, Cuba and Argentina show a high degree of homogeneity (HAI equal to 1.000, 0.946 and 0.936, respectively), other countries register values of this index close to 0.700. Haiti is the country with largest heterogeneity in attainment of relative achievements of indicators considered (HAI = 0.000).

The HDEI results for the 23 countries studied are presented in Table 3.

The five countries with the highest HDEI values are, in de-creasing order, Cuba, Uruguay, Argentina, Costa Rica and Chile.

While the five with lowest values are (also in decreasing order) Honduras, Nicaragua, El Salvador, Guatemala and Haiti. Another indication of the region’s evident disparity is that the maximum HDEI (Cuba) is 6 times higher than the minimum one (Haiti).

For all the countries, the resulting HDEI is value is lower than the HDI.[39] This could be indicating, as previously pointed out,[40] that the achievement gap in important aspects of human development, the absence of equity in human groups inside countries and the meager impact of income on human development all affect human development in LAC countries. This result deserves more incisive analysis.

The weight of economic resources –measured by the GDP per capita (PPP US$) – in the indices leads to contrasting

results between the HDI and the HDEI. Economic resources have much less weight in the HDEI than in the HDI. While almost 85% of the changes in the HDI can be explained by variations in the GDP per capita (PPP US$), the effect of this indicator on the HDEI is reduced to 57% - that is, one and a half times less. Thus, the HDEI would seem closer to a comprehensive measurement of human development than HDI, isolating – though not ignoring – the effect of economic resources on such development.

Table 3:. HDEI Values - Latin American and Caribbean Countries; c 2002

COUNTRY HDEI

Cuba 0.7913

Uruguay 0.7776

Argentina 0.6917

Costa Rica 0.6793

Chile 0.6459

Trinidad & Tobago 0.6122

Paraguay 0.6000

Jamaica 0.5822

Venezuela 0.5822

Panama 0.5754

Mexico 0.5708

Ecuador 0.5637

Colombia 0.5614

Brazil 0.5420

Guyana 0.5213

Peru 0.4764

Dominican Rep. 0.4586

Bolivia 0.4391

Honduras 0.4066

Nicaragua 0.3474

El Salvador 0.3308

Guatemala 0.3244

Haiti 0.1306

Figure 1: Lorenz Curve and Gini Coefficient of the Distri-bution of Physicians per Population - Latin American and Caribbean Countries; c 2000

Figure 2: Human Development and Equity Index and Homo-geneity of Achievement Index/Latin American and Carib-bean Countries


At the same time, as can be observed in Figure 2, strong positive correlation exists between the HDEI and the HAI; that is, the more homogenous a country is in the achievement of partial aspects of human development, the more global human develop-ment achieved.

The Relative Efficiency Indices for four results indicators related to human development as a function of GDP per capita (PPP US$) are shown in Table 4 as an indicator of economic resources for the country considered. Only 4 countries – Cuba, Uruguay, Honduras and Venezuela – show positive indices for the 4 indicators; 17 countries have positive indices for some indicators and negative ones for others (which could be indicat-ing an unequal use of their economic resources), and 2 countries –Trinidad & Tobago and Haiti – show negative indices for all 4 indicators.

To evaluate efficiency in the use of economic resources for global human development in each country, the Modified Human Development and Equity Index (MHDEI) was used, that is, the HDEI not considering the transference of economic resources component in human development. Thus, the MHDEI is a function of two components: achievement in important areas of human development (C1) and equity in human groups inside the country (C2), with the condition that the component that contributes more

to the index value is the one that discriminates most. Once these calculations are carried out, both components are equally pondered, so the index will have the following expression: MHDEI = ½ C1 + ½ C2.

Table 4: Relative Efficiency Indices for Results Indicators Associated with Human Development as a Function of GDP per capita (PPP US$), Latin America and Caribbean Countries

COUNTRYINDICATOR

ADULT LITERACY RATE

HEALTHY LIFE EXPECTANCY

% POPULATION W/ ACCESS TO DRINKING WATER

PHYSICIANS (X 10000 pop.)

Cuba 0.5598 0.9612 0.7701 1.0000

Uruguay 0.2682 0.2718 0.7975 0.4608

Honduras 0.0515 0.3936 0.9172 0.0117

Bolivia 1.0000 -0.1534 0.5025 -0.3321

Ecuador 0.6997 0.3938 -0.1463 0.0464

Jamaica 0.1878 0.7681 0.2012 -0.4257

Venezuela 0.2474 0.2607 0.0494 0.0853

Nicaragua -0.4628 1.0000 -0.0019 -0.0969

Costa Rica 0.0411 0.3568 0.5227 -0.5443

Panama 0.0479 0.4604 0.1976 -0.4285

Chile -0.0058 0.3114 0.4075 -0.6821

Guyana 0.9577 -1.0000 1.0000 -0.9714

Argentina 0.0083 -0.0765 -0.2900 0.2364

Colombia 0.0023 -0.2727 0.4352 -0.6698

Mexico -0.2311 0.0507 -0.0352 -0.3091

Peru 0.1256 -0.2009 -0.1645 -0.4510

Brazil -0.4026 -0.8144 0.1753 0.0455

Dominican Rep. -0.5207 -0.7233 0.1884 0.0292

Haiti -0.4181 -0.7516 -0.1349 0.0907

Paraguay 0.4642 0.0513 -1.0000 -0.8407

Guatemala -1.0000 -0.5611 0.1552 -0.2472

Trinidad & Tobago -0.1341 -0.5648 -0.0596 -1.0000

El Salvador -0.5632 -0.3971 -0.5924 -0.2434

Figure 3: Real and Estimated MHDEI as a Function of GDP per capita (PPP US$) Latin American and Caribbean Countries; c 2002

HON

PAN


Figure 3 shows the location of the countries and the adjustment function obtained. Those countries located above the adjustment function have achieved a higher human development than expected from their economic resources; while those located below the adjustment function have a lower human development than would be expected from their economic resources.

Figure 4 shows the Relative Efficiency Indices in achievement of human development and equity as a function of available economic resources.

Among the group of 23 countries considered, 13 show positive efficiency in the achievement of human development and equity as a function of their economic resources. The countries that achieved greater translation of their economic resources into human development and equity among the LAC countries are Cuba, Paraguay and Uruguay.

According to their GDP per capita (PPP US$) and us-ing the experience of the 23 countries, Cuba should have an MHDEI of 0.552 instead of the 0.714 it does have. Paraguay should have 0.526 instead of 0.676; and Uruguay, 0.612, instead of 0.753. The countries with highest negative efficiency were Guatemala and El Salvador. These countries should have an MDHEI of around 70% and 60% respectively, higher than the ones they show.

To summarize, it can be said that extraordinary inequali-ties become apparent among LAC countries with respect to achieving essential aspects of human development. In relation to economic resources, there are countries where the GDP per capita (PPP US$) does not even reach one third of others (Bolivia, Haiti, Honduras and Nicaragua with respect to Argen-tina, Chile, Costa Rica and Trinidad & Tobago, for example). A basic service such as sustainable access to safe drinking water is enjoyed by almost all the population in some countries (for example, Colombia, Costa Rica, Cuba and Uruguay), while in

others (such as Haiti and Paraguay), scarcely half the popula-tion has access to it.

Distribution of such a fundamental health resource as physicians is so different that 1 out of every 6 physicians in the region would have to be redistributed to achieve an equitable distribution according to the population they serve. Seventy percent of the LAC population has access to only 40% of the existing physicians.

There is an abysmal difference in life expectancy, where a person born in some countries is expected to live a decade or more than one born in practically bordering countries. An example is the difference of more than 20 years between Cuba, Chile or Costa Rica and Haiti; or the difference of over 10 years comparing these same three countries to Bolivia and Guatemala. Inequality in the balance these countries show in attaining few or many of these achievements must be added to these differences in specific achievements. Quantifying hu-man development and equity by a synthetic indicator – the Human Development and Equity Index – reveals a six-fold difference between the country with the worse result (Haiti) and the country with the best performance (Cuba).

At the same time, it is demonstrated that the more homogenous a country is in achieving specific aspects of human development, the greater the global human development it attains. In addition, countries have exhibited various levels of efficiency in translating economic resources into human development (the most efficient - Cuba, Paraguay and Uruguay; the most inef-ficient - El Salvador and Guatemala). From the point of view of measurement, the Human Development and Equity Index seems to be closer to a comprehensive

measure of human development than the Human Development Index, since it more clearly isolates the effect of economic re-sources on the index.

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1. PNUD. Desarrollo humano; informe 1990. Bogotá: Tercer Mundo Editores; 1990. Cap. 1.

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Figure 4: Relative Efficiency Index for Human Development and Equity as a Function of GDP per capita (PPP US$) Latin American and Caribbean Countries; c 2002


Abelardo Ramírez Márquez, MD, PhD Guillermo Mesa Ridel, MD, MPH

Many governments have expressed their desire to reduce the unjust, and unjustifiable, inequalities that affect different social groups. While this concern is not new, there has never been such an enormous scientific and technical potential to right this wrong, never such an extraordinary capacity for wealth generation and, hence, redistribu-tion.[1]

Significant contemporary scholars like John Rawls, Am-artya Sen and Margaret Whitehead have attempted to study, define and interpret the concept of equity as it relates to social justice and public health. Some of them, starting out from the premise that good health and a state of well-being is potentially available to all, have claimed that a just society should secure for every one of its members the same basic liberties, the same rights to political participation, and the same opportunities. Seen from this point of view, equity confronts the rule of law with the notion of justice.[2]

CUBAN PROFESSIONAL LITERATURE - REVIEW ARTICLE

Equity in Public Health: A Challenge for Disaster Managers

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This article is based on a paper of the same title presented at the 25th International Congress of the Latin American Studies Association, Nevada, October, 2004. Reprinted by permission of the authors.

THE AUTHORS

Cándido M. López Pardo, Full Professor, University of Havana, Cuba. Miguel Márquez, Distinguished Professor, University of Cuenca,

Ecuador and Visiting Professor, University of Havana, Cuba. Francisco Rojas Ochoa, Distinguished Professor, Higher Institute of

Medical Sciences, Havana and Consulting Professor, National School of Public Health, Havana. Contact: [email protected]


Gender, age, race, ethnic background, and geography - not to mention income - can all affect individuals’ access to health care and other vital services that also influence the overall degree of health and well-being. In spite of the enormous technological and scientific advances of recent decades, communicable diseases remain the most frequent cause of death in today’s world among those living on the margins of society, underscoring the growing health inequity at both the international and national levels.[3] It is another facet of the unequal production, distribution and consumption of goods and services, including education and cultural expression.

The impact, magnitude, and recurrence of disasters in the Americas has less to do with the absolute characteristics of natural hazards - wind speeds, in the case of hurricanes, or rainfall levels in the case of floods - than with the social, economic, environmental, institutional and other circumstances of the victims. In that sense, vulnerability is social. Generally, adverse natural phenomena cause the greatest damage among those social groups living in the most fragile conditions: peasants, indigenous peoples, the urban poor - broadly speaking, the excluded.

There is little reason to hope that the current development model - which is predatory and unsustainable - can right this wrong. As the masses become poorer, they also lose political power and spaces for participation, while increasingly feeble nation-states reduce their social investment and lose their response capacity even as vulnerability grows. International aid, meanwhile, can at best attenuate the impact of disasters once they have already occurred, instead of providing lasting solutions in the form of soft loans to improve poor countries’ capacity to increase their exports, raise employment levels, and obtain the necessary revenue to fund disaster prevention programs.

In this context, it makes little sense to propose policies for improving the health of the general population without addressing the question of equity.[4] Efforts must focus on the inclusion of the disadvantaged, including women, children, the elderly, the disabled, and ethnic minorities. While their losses in disaster situations are low in absolute terms, due to their very poverty, relative losses are high given the impact on their standard of living.[5] This calls for the institutionalization of citizen participation mechanisms.

However, health inequities cannot be eliminated simply by reducing poverty, since they can still be found in those countries that provide the poorest groups with access to health and medical care, sanitary education and welfare and unemployment benefits. Inequities appear as a health gradient throughout the social hierarchy, not only among the least advantaged. It is essential to understand that disasters are caused by social and political struc-tures, and are not the result of chance or bad luck. In the field of health and disaster prevention, all countries must work together to introduce the necessary changes. The current world economic crisis is affecting everyone - with one proviso: the rich are less af-fected; the poor, more. This means that the impact of the crisis is not the same for all individuals or all countries.[6]

Thus, in addition to medical services, the population must have equitable access to education, culture, sport, and all other ways to improve their well-being. And a key part of this must be a carefully crafted, multidisciplinary disaster reduction plan involv-ing all relevant institutions and community organizations.

In Cuba, the foundations have been laid for knowing the hazards that can affect every community and every health facil-ity, based on their vulnerabilities, and a monitoring and train-ing plan has been developed for all relevant human resources.

Public health institutions play their role in disaster reduction through teams of multidisciplinary specialists who work closely with all other sectors at the local level, employing a methodol-ogy that includes early warning, preparedness and response. The recent infestation by the Aedes aegypti mosquito and the resultant dengue epidemic that affected the country, most severely in Havana, put us to the test, forcing us once again to develop comprehensive interdisciplinary solutions based on health equity - that is, the allocation of resources where they were most needed.

With the valuable assistance of UNICEF, the Pan American Health Organization (PAHO), DIPECHO and other international organizations, and the cooperation of non-governmental organiza-tions, we are perfecting our integral approach to disaster preven-tion and mitigation, and efforts are underway to make the best possible use of the country’s scientific capabilities with a view to coordinating as a whole all prevention activities, including research and information, the coordination of relief and rescue efforts, and the handling of sanitary and epidemiological concerns - not to mention greater international cooperation, particularly with Latin America and the Caribbean, in fields such as forecasting, emergency assistance and training.

At present, we are involved in the design of a Health Equity Monitoring System for Cuba [see first Cuban Professional Litera-ture article] that should respond dynamically to warnings of pos-sible health inequities and view them not only territorially and in terms of the groups involved, but also over time, so that decisions can be made to ensure the highest degree of health equity. The project benefits from the political will of the government to see it executed, the existence of reliable information, and the quality of the human resources involved in it. The integral approach favored by our National Health System in the field of natural or man-made disaster prevention and mitigation has made it possible to build capabilities for preparedness, early warning and response in con-nection with this world-wide problem. It also places us in a position to collaborate and provide assistance to the countries of the region and the world, something we are gladly willing to do.

REFERENCES

1. F. Castro. Inaugural Speech, South-South Summit, Havana, April, 2000.

2. PAHO/WHO. Principles and Basic Concepts of Equity and Health, Division of Health and Human Development, 1999.

3. P. Hartigan. Communicable Diseases, Gender, and Equity in Health. Cambridge, MA: Harvard Center for Population and Development Studies, 1999.

4. International Strategy for Disaster Reduction (ISDR), Pan-American Health Organization (PAHO/WHO). Hurricane Mitch: A Glance at Some Thematic Trends in Risk Reduction in Central America. San José, Costa Rica: ISDR, 2000.

5. Dr. Abraham Sonis. Speech accepting PAHO’s Abraham Horwitz Award for Leadership in Inter-American Health. Pan-American Health Review 8(5):359-62, 2000.

6. F. Castro. Remarks at the 11th Ibero-American Summit, Lima, November, 2001.

THE AUTHORS

Abelardo Ramirez, 2nd Degree Specialist in Health Organiza-tion and Management (Deceased)

Guillermo Mesa Ridel, Director, CLAMED


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By Conner Gorry

Hurricane Wilma was a record breaker and history maker, escalating from a tropical storm to a full-blown Category 5 hurricane in a matter of hours, making it the fastest intensification of any storm on record. By the time it sideswiped Cuba on October 23rd, lashing coastal regions with 20-foot waves that traveled almost a half mile inland, it had mellowed to Category 3 - still powerful enough to rip electrical posts from the ground, send roofs flying and flood some Havana neighborhoods beyond recognition.

Nevertheless, there was zero loss of life on the island, in contrast to other experiences in the region, with 12 dead in

Haiti, two in Jamaica, eight on the Yucatán Peninsula and five in Florida. Cuba’s minimal loss of life from this and even stronger storms is by design: internationally recognized as efficient, ef-fective and replicable, the disaster preparedness system in the hurricane-thrashed nation has proven that accurate information given early and often, combined with a series of coordinated measures, can save lives.

Forecasting, Cuban authorities have found, plays a critical role. A full 96 hours before a tropical storm or hurricane is expected to hit the island, the National Forecast Center issues an Early Advisory. This is followed by an Information Phase, 72 hours before, when all media begin special reports on the trajectory and progress of the storm. At this time, the public starts preparing for a possible

HEADLINES IN CUBAN HEALTH - TOP STORY

Hurricane Wilma: Living to Tell the Tale


hurricane strike, taking measures they’ve learned over the years - including storing potable water, stocking up on non-perishable food and securing doors and windows of their homes. At this stage, civil defense officials also begin reviewing and updating disaster plans.

Cuba is one of the few countries that use these Early

Advisory and Information Phases as preludes to the Hurricane Watch (48 hours before a strike is expected) and Hurricane Warning (24 hours before). According to Dr. José Rubiera, Direc-tor of the National Forecast Center, “by the time we issue the Hurricane Warning, almost everything is in place.”

As the storm rolls in, above-ground electricity is cut when winds reach about 40 miles an hour, preventing electrocution deaths caused by downed wires – a common cause of hurricane-related fatalities. Some Havana residents grumbled that their power was cut too early in slow-moving Wilma’s trajectory, leaving them without electricity for hours before the fiercest winds hit. Nevertheless, they called the precaution itself necessary.

Evacuate….Or Not

Cuba’s evacuation proce-dures prioritize vulnerable populations, from pregnant women and the elderly to residents in low-lying villages; and importantly, transportation is provided for all those evacuated. During Wilma for instance, the entire seaside community of Playa Rosario on the southern coast of Havana Province had to be moved to safer ground, so scores of buses were brought in to evacuate the townspeople. Once the storm had blown through, only three of 113 homes were left standing, but no injuries or loss of life were reported.

In a country heavily dependent on revenue from foreign visitors, evacuation of tourists - during Wilma, over 1,000 were moved inland from seaside hotels and resorts - is also a major component of Cuba’s disaster preparedness plan. MEDICC Review staff witnessed evacuation from one Havana hotel, where evacuees were ushered out and briefed in English and Spanish where they were going and what to expect. Tourism officials estimated that installations affected by the storm would be up and running within a month.

Yet, evacuation ahead of impending disaster is a tricky equation, as no one wants to abandon their home to nature or potential thievery. Like elsewhere, evacuation in Cuba is voluntary. Still, the government provides some innovative services to make it more palatable and practical, including setting aside warehouse space for household valuables like TVs and appliances and guaranteeing safe evacuation and shelter space for pets. Medical attention, food and water are also guaranteed at evacuation shelters. Yet, some don’t heed the warnings, and simply stay behind - to be evacuated after the storm hits and under more precarious circumstances.

Although no lives were lost during Wilma’s wrath, many homes were not as fortunate. Calamitous flooding in coastal areas in Western Cuba brought severe damage, with interminable ocean swells pouring seawater over Havana’s Malecón seaside drive, pounding parts of the Playa, Centro Habana, Habana Vieja and Vedado neighborhoods. When October 24th dawned on the city, the streets ran with knee-high and even shoulder-high water in some places, sparking the evacuation of 31,000 more residents from those areas, many who had to leave their belongings behind, floating in flooded homes.

Many said despite warnings, they were caught by surprise since flooding like this hadn’t been seen in Havana since the 1993 “Storm of the Century.” A resident of 5th and E Streets in Vedado was frantically moving his valuables to his neighbor’s house on the second floor when a boat came to evacuate him with his wife. “The water came up so fast as we were stowing our things with our neighbor,” he told MEDICC Review shortly after wading to dry ground. “Our three kids are already at a friend’s house, and that’s where we’re headed now. We’ll go back and see the damage when the water recedes,” he said.

One immediate concern for authorities was contaminated drinking water, as result of saltwater-flooded cisterns. Trucks pumping potable water into homes could be seen around Havana

A mother and daughter move to higher ground in Havana´s Vedado district during Hurricane Wilma.

Evacuations from flooded areaswere carried out by specialist teams in small boats.

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One immediate concern for authorities was contaminated drinking water, as result of saltwater-flooded cisterns. Trucks pumping potable water into homes could be seen around Havana the day after the storm, while public health workers emptied saltwater from the compromised cisterns, flushed them with fresh water and treated them with chlorine. Several days later, public health teams returned to test cistern water for contamination.

Looking a little like Venice - with rescue teams in Zodiacs instead of men paddling gondolas - the streets-turned-canals were cordoned off by police, while authorities coordinated rescue missions. “Some members of our congregation - including old folks - are still in there,” said Pastor Estela Hernández of the William Carey Baptist Church, pointing to the flooded neighborhood beyond the corner of Línea and K Streets where she stood. Pastor Hernández was waiting to see them to safety, and if need be, to the shelter of her Vedado church with other evacuees.

In some cases, doctors were shuttled into the flooded areas by boat, and the Cuban Red Cross erected a mobile hospital at the intersection of Paseo and Línea Streets. People suffering from asthma stranded in their homes were of particular concern. Doctors on duty at the Camilo Cienfuegos Hospital emergency room in the heart of the flooded neighborhood told MEDICC Review they had seen several asthmatic patients, but few injuries.

For those returning home, the wreckage was heartrending. “This is very, very hard,” said Enrique Álvarez of the Colón section of Centro Habana, looking upon his apartment, flooded knee-high with flotsam and saltwater. “No one thought the water would come up this far. My neighbor came in and saved some of my things and I’ll salvage what I can,” the filmmaker told MEDICC Review. The full extent of the damage to the city’s buildings will reveal itself over time, since the combination of voluminous water and salt will undermine structures already in disrepair, according to experts.

Storm Lessons

Once the floodwaters receded, the Recovery Phase - dubbed Operation Aurora - of the Cuban disaster management plan was nearing completion, and the cleanup task ahead loomed large. Massive volunteer efforts in the effected areas eased that task, and

A neighbor from 5th and E Streets is evacuated by boat with his wife and a few belongings. “We’ll go back and see the damage when the water recedes.”

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flood zone residents received boosts with food disbursements, new mattresses, televisions and fans from the government. Doctors and nurse teams meanwhile, went house to house, conducting heath assessments. The work is far from over for disaster planners and health and state authorities, as post-hurricane is the time to analyze storm-provided lessons and fold that knowledge into the overall strategy, to be better prepared next time.

A recent evaluation looked at Hurricane Dennis that hit eastern Cuba last August – taking the lives of 16 people, the number of combined hurricane deaths from 1996-2002 throughout Cuba. The tough assessment revealed too much of an improvised approach by some Civil Defense coordinators; too little evacuation from vulnerable areas; the use of inadequate buildings for some shelters; and poor provisioning in others.

Undoubtedly, lessons from Hurricane Wilma will focus on the effects of intense flooding; early, efficient evacuation of littoral zones; and different risk management approaches for very slow-moving hurricanes like this one. One lesson, though, has always dictated disaster preparedness strategy in Cuba: the protection of human life is the highest priority.

To learn more about Cuba’s strategy, see MEDICC Review online “Disaster Management in Cuba: Reducing the Risks,” Vol. VI, No. 3, 2004.

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A doctor is taken into the flood zone to attend to health needs.

By MEDICC Review Staff

China’s first monoclonal antibody facility, the result of a technology transfer from Cuba, has begun producing hR3 (Ther-aCIM), a genetically engineered humanized monoclonal antibody effective for advanced epithelial cancers of the head and neck resistant to chemotherapy.

TheraCIM was developed by Havana’s Center for Mo-lecular Immunology (CIM), the same institution responsible for a therapeutic lung cancer vaccine (SAI-EGF), now licensed for development and marketing to the California-based CancerVax Corporation (see MEDICC Review online, Headline U.S. Com-pany Licenses Three Cuban Cancer Vaccines, Vol. VI, No. 1, 2004).

The September opening of the new plant in Beijing’s in-dustrial development park caps over a year of TheraCIM efficacy trials in China, revealing 70% of the 120 patients enrolled to be fully responsive to treatment, according to Prensa Latina News Agency. Head and neck cancers account for nearly one third of cancer localizations in China, the agency reports, and the pro-duction facility will initially manufacture eight kilograms of the

antibody annually, or enough for approximately 10,000 patients. At full capacity, 62,500 patients could be treated.

Thus far, TheraCIM has been patented in the United States, Canada, China and various European countries, while technol-ogy transfer has been negotiated with India as well as China. In 2002, the product was awarded the World Intellectual Property Organization’s Gold Medal.

Production and marketing of TheraCIM in China is under the auspices of Biotech Pharmaceutical, a joint venture established in 2000 between Chinese companies and CIMAB (CIM’s com-mercial representative). Under the original agreement, Cuban specialists transferred technology and production know-how consistent with international norms and regulations. Dr. Patricia Sierra, who leads the Cuban end of the partnership, notes that the new plant also permits production of other monoclonal antibod-ies and recombinant vaccines, and lays the foundation for joint cancer research. A second joint medical project was inaugurated in late September in China’s Jilin Province, a facility to produce and market Cuban vaccines and recombinant therapeutic proteins developed by Havana’s Center for Genetic Engineering and Bio-technology (CIGB).

HEADLINES IN CUBAN HEALTH

China’s Cancer Patients To Benefit from Cuban Biotech

By the Numbers: Hurricane Wilma • People evacuated: 607,542 (over 537,200 with friends or family, the rest in shelters)• Number of shelters: 1,325• Animals moved to higher ground: 413,850• Volunteers mobilized: 103,000• Greatest wind gusts: 86 mph• Greatest sustained winds: 67 mph


By Gail A. Reed and Julián M. Torres

Three university campuses in Cuba began offering a degree in biomedical engineering this fall, responding to greater national and international demand for graduates in the field. Biomedical engineers specialize in the design, production, safety and efficient utilization of medical equipment ranging from x-rays, incubators and operating theater accessories, to MRIs, gamma cameras and other imaging equipment.

Cuba’s Ministry of Public Health recently refurbished over 400 outpatient clinics in the country, installing diagnostic ultrasound and several other technologies for the first time at the community level. The country’s hemodialysis capabilities have also been increased from 32 to 47 centers distributed throughout the island. And some 50 Cuban hospitals are now undergoing capital improvements to render them “national centers of excellence,” significantly upgrading services with the purchase of new equipment.

All this, plus the demand for Cuban biomedical experts and teachers for such countries as Venezuela, Guatemala, South Africa and Honduras, put the new field on the academic fast track. For some time, biomedical technicians have been trained in Cuba - where the specialty was studied primarily by electrical engineers in post-graduate programs - and by Cubans abroad.

“In developing countries where Cuban doctors are serving,” notes Dr. Yiliam Jiménez of Cuba’s international Comprehensive Health Program, “they began finding medical equipment of all kinds gathering dust or simply junked for want of expertise to repair it. This is how our collaboration began in the field - by sending Cuban technicians to many of these places, to teach and to train.”

In the case of medical equipment, science has been added to the same resourcefulness born of economic difficulties that keeps 1950s American cars running in Havana today - and Cubans’ results in many countries have convinced governments that biomedical maintenance can save millions of dollars, not to mention lives. (See MEDICC Review online, International Cooperation Report Ingenuity and Solidarity: A Lifesaving Combination, Vol. VII, No. 1, 2005).

In 2003, Cuban universities initiated a five year Bachelor of Science program in the field, enrolling primarily South African students, according to Dr. Juan J. Ceballos of the Vice Ministry of Health for Medical Education. The B.S. program, he told MEDICC Review, is designed to allow students to receive a ‘basic-level technician’ diploma after successfully completing two years and a ‘middle-level technician’ diploma after three years, going on to opt for a university degree after the full five years. Thus, these students can enter the workforce with some level of expertise at points along the way if necessary.

By Anna Kovac

A Cuban ophthalmology center, public health educator and virologist garnered awards and worldwide recognition for excellent work recently. The Camilo Cienfuegos International Retinosis Center in Havana received the Ibero-American Quality Award for Excellence during the 15th Summit in Salamanca, Spain, in October. The center has treated over 8,000 patients from 85 countries for a variety of eye afflictions, especially retinitis pigmentosa. In Cuba, there is a retinosis center in each of the 14 provinces that provides care for all patients near their home.

The retinosis therapy Cuban Dr. Orfilio Peláez created and put into practice in the center in 1992, is considered an effective treatment for this hereditary disease that can lead to total blindness. The groundbreaking treatment combines surgery, ozone therapy, electrostimulation, magnetic therapy and prescription medicines. A four-year study designed to determine the characteristics of the disease in Cuba that has a prevalence rate of 4.1 per 10,000 inhabitants, affecting 4,123 patients in 2,435 families, is currently underway; it’s slated to end in 2009.

Earlier in Washington, D.C. during the 46th Meeting of PAHO’s Directing Council, the regional health organization

awarded a Cuban, Chilean and Argentine for their work in medicine, teaching or research.

Cuban physician Francisco Rojas Ochoa (see MR Interview Francisco Rojas Ochoa) received the 2005 PAHO award in Health Administration for his “excellent contribution to the training of generations of professionals and public health leaders.”

Dr. Patricia Sorokin from Argentina received the Manuel Velasco-Suárez Award in Bioethics and Chilean Dr. Ricardo Uauy, a top nutrition expert, received the Abraham Horowitz InterAmerican Health Leadership Award.

Finally, in its 125th anniversary issue, the US magazine Science recognized the work of Cuban research scientist, Dr. María Guadalupe Guzmán, head of the Virology Department at the Pedro Kourí Institute of Tropical Medicine in Havana. The Cuban specialist was among 12 researchers worldwide whose essays were published in the journal.

Science published Dr. Guzmán’s study “Deciphering Den-gue: the Cuban Experience,” (Vol 309, September 2, 2005), which details epidemiological, virological and clinical dengue research in Cuba. Dengue is considered one of the greatest threats to health in the world today, infecting 50 million annually.

Cuban Medicine Receives International Recognition

Biomedical Engineering Degree Debuts in Cuba


Reprinted by permission of the International Federation of Red Cross & Red Crescent Societies. For full report, go to http://www.ifrc.org/publicat/wdr2005/index.asp.

From August to November 2004, nine hurricanes raked the Caribbean. At least 2,000 people were killed. Hundreds of thousands were left homeless. Economic losses totalled over US$60 billion. Haiti suffered by far the greatest human toll. Yet Cuba, Jamaica and the Dominican Republic, while hit very hard, suffered relatively low death tolls. Why? Much of the difference comes down to knowledge and warning. The chapter reveals that local organization and awareness are as important as timely, ac-curate hi-tech warnings.

During 2004, Cuba proved how effective it is in protecting human life from windstorms. When Hurricane Charley hit in Au-gust, 70,000 houses were severely damaged and four people died. When Hurricane Ivan swept past a month later, over 2 million people were evacuated but no-one lost their lives.

Cuba has a world-class meteorological institute, with 15 provincial offices. They share data with US scientists and project storm tracks. Around 72 hours before a storm’s predicted landfall, national media issue alerts while civil protection committees check evacuation plans and shelters. Hurricane awareness is taught in schools and there are practice drills for the public before each hurricane season. Most adults are reasonably well educated, so they understand what officials and forecasters tell them.

With the storm 48 hours away, authorities target warnings at high risk areas. Local officials check that vulnerable people can evacuate. Finally, with 12 hours to go, everyone who needs to be evacuated should be in shelters, homes must be secured, windows boarded up and neighbourhoods cleared of loose debris. These are the legal requirements in Cuba, and they were enforced during Charley and Ivan. According to Audrey Mullings, a Jamaican Red Cross volunteer: “The best thing to learn from Cuba is that you don’t need a lot of money to make things work.”

In Jamaica, the prime minister went on national radio and TV the day before Ivan hit to remind people that the storm had just killed 39 in Grenada. Jamaica’s meteorology office benefits from US forecasts which predicted where the storm would make landfall to within 50 km. Volunteers from the Jamaican Red Cross and Parish disaster committees issued street warnings, called resi-dents by cell phone, checked shelters were ready, watched rivers for signs of flooding, and borrowed private vehicles to evacuate the blind and disabled.

Since Hurricane Gilbert in 1988, there have been great improvements. The country’s disaster preparedness office has mapped flood and landslide hazards, developed community-based

warning systems and maintained a year-round public awareness programme. June is ‘disaster preparedness month’, during which awareness days, practice drills and displays are organized. These factors helped keep the death toll during Ivan down to 17.

Dominican Republic shares Hispaniola island with its neighbour Haiti. When Tropical Storm Jeanne dumped record rains during mid-September, rivers overflowed – 23 Dominicans died, 40,000 were rescued and 2 million were affected. The day before, the meteorological institute is-sued a warning and maps showing the storm’s likely path. News quickly reached even the smallest settlements. Radio stations relayed the message. Some received cell phone calls from relatives in Puerto Rico, who’d seen the storm approaching on TV. Others got the news from local may-ors riding into rural areas by horseback or motorcycle.

However, people focused on the wind rather than flooding. Many decided not to evacuate, because they lived in wind-safe houses. Some awoke to find their houses flooding. One family of 11 spent the night up a tree, until they were rescued with a home-made raft.

Over the border in Haiti, Jeanne’s rains inundated the coastal town of Gonaives. Floodwaters rose two metres in 30 minutes, killing 1,800 people and leaving 800 missing. Why did the same storm carry away 100 times more Haitians than Dominicans? Jeanne’s rains lashed deforested mountain slopes, causing deadly landslides. The sudden departure of President Aristide seven months earlier had led to great instability and rioting. Early warning systems require local government to prepare people, convey warnings, monitor events and help evacuate. The system existed on paper but didn’t function in practice.

Haiti’s meteorological centre lacked resources. The country’s emergency operations centre wasn’t working. Warnings never made it to Gonaives. When the storm struck, most residents thought the mountains would shield them. They had no idea what was about to hit them. Over the last 60 years, hurricanes have killed 17,000 Haitians. Clearly Haiti needs help to reinforce its preparedness and warning systems.

Effective hurricane warning requires both technology and people-to-people communication. Secrets of success in the Carib-bean include:

1. Hurricane forecasting: the US shares its forecasting tools with the region – providing accurate forecasts 3-5 days in advance. Cuba supplements these with its own radar and computer models. Challenges remain – par-ticularly in forecasting hurricane intensity.

INTERNATIONAL VOICES

World Disasters Report 2005 Chapter Two: Run, Tell Your Neighbour! Hurricane Warning in the Caribbean


2. National warning: Authorities should convey initial 3-5 day alerts, followed by specific warnings to trigger pre-ventative action 24 hours before the hurricane’s expected landfall.

3. Local government: provides the vital link between national level warnings and communities at risk. Local officials must have resources available for warning and evacuation. Warnings should include localized detail on possible flooding and landslides – often more deadly than high winds. If local government is weak, the warning chain breaks.

4. Civil society participation: not even in Cuba can the govern-ment do everything. Civil society – including local NGOs, Red Cross, church and youth groups – must pitch in. This involves trusting official warnings.

5. Popular understanding and action: vital to Cuba’s success in hurricane preparedness. Public awareness campaigns – through schools and practice drills – are essential.

The technology of early warning is the easy part – the real challenge lies in making it people-centred:

• Make warnings intelligible: People at risk need to know what to do when they get a hurricane warning. Increasing basic literacy will help.

• Make warnings specific: National warnings must be supplemented with local warnings of flooding and land-slides.

• Encourage local ownership: early warning systems are more likely to succeed if people at risk participate in designing and maintaining them.

• Supplement local knowledge: personal experience and oral history are important – but not always reliable. Experience must be discussed critically and supplemented.

• Spread awareness through schools: children who are aware of hurricane hazards spread awareness through their families and neighbourhoods, and become more receptive as adults.

• Link warning to risk reduction: Investment to tackle root causes of vulnerability, such as uncontrolled urbanization and deforestation, is urgently needed.

Principal contributors to this chapter were Ben Wisner, Vic-tor Ruiz, Allan Lavell and Lourdes Meyreles. Ben Wisner, is an independent researcher affiliated with the Development Studies Institute at the London School of Economics, the Benfield Hazard Research Centre (University College London)and the Disaster Prevention Research Institute at Kyoto University, Japan. Victor Ruiz is an independent consultant and sociologist based in the Dominican Republic. Allan Lavell, is the coordinator of the risk and disaster research programme at the Secretariat General of the Latin American Social Science Faculty (FLACSO) and the Latin American Network for the Social Study of Disaster Prevention. Lourdes Meyreles is a sociologist who coordinates FLACSO’s Dominican Republic programme. Ruth Chisholm, the Jamaica Red Cross’s director of emergency services and communication, contributed this Box.

Jamaica’s community disaster response teams

“I was glad that I could warn them before the storm”, says Patricia Greenleaf simply. Patricia is a member of the Jamaican Red Cross’s community disaster response team (CDRT) for Cedar Valley. Along with dozens of other volunteers, she went from street to street issuing warnings by megaphone, 48 hours before hurricane Ivan hit. They encouraged marginalized groups and people with special needs – including the elderly and mentally impaired – to hang a white flag or piece of material outside their home to signal that they needed help when the time came for evacuation.

Hurricane Ivan, the most powerful storm the Carib-bean had seen for 50 years, had just pounded Grenada with 250 km/h winds, killing 39 people and damaging or destroying 90 per cent of the island’s buildings. The Jamaica Red Cross put all its branches and 12,000 volunteers on high alert. They opened 1,000 community shelters across the country.

When ‘Ivan the Terrible’ struck Jamaica on 11 Septem-ber 2004, Patricia’s team was ready. They had prepared a local map detailing potential risks and resources. They knew where Cedar Valley’s most vulnerable people lived. They had drawn up a community response plan, with the local Red Cross branch. They were already trained to carry out light search and rescue, emergency first aid and rapid assessment. And they were equipped with medical kits, megaphones, shovels, rope, waterproof boots and helmets. Despite widespread damage to prop-erty, no one in Cedar Valley died during the storm.

Published by MEDICC, Medical Education Cooperation with Cuba1902 Clairmont Road, Suite 250, Decatur, GA 30033. Available online at: www.medicc.org

Reproduction authorized with appropriate citation.

medicc · rojas ochoa, md, phd, mph 28 equity in public health: a challenge for disaster managers...

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