Pugwash Meeting No. 240
Public Health Systems in Developing Countries
6-8 October 1998, Havana, Cuba
Report by Jeffrey Boutwell
Pugwash Workshop on Public Health
THE Pugwash workshop on Public Health Systems in Developing Countries was held in Havana, Cuba, 6-8 October 1998, with the cooperation of the Cuban Pugwash Group and the Cuban Movement for Peace and Sovereignty of People. More than 50 participants from 12 countries attended the workshop. The meeting opened with welcoming remarks from Lic. Orlando Fundora Lopez, President of the Cuban Movement for Peace, Prof. Jose Altshuler, President of the Cuban Society for the History of Science and Technology, and Prof. George Rathjens, Secretary General of the Pugwash Conferences.
Public Health Indicators
THE workshop began with a presentation on hygiene and epidemiology in Cuba, prior to and following the revolution of 1958. Mention was made of the contributions of Dr. Carlos Finlay, the 19th century Cuban discoverer of the transmitting agent of yellow fever who also designed a method for effectively eradicating the disease. In the early 20th century, Finlay studied ways of eradicating malaria, bubonic plague and variola (smallpox) on the island. The early 1960s witnessed the beginning of a marked increased in hygiene improvements and the formation of public health facilities and polyclinics. The creation of this public health network increased the availability of vaccinations and helped to achieve the elimination of polio (1962), diphtheria (1969), neonatal tetanus (1972), meningitis (1989) and measles (1993). In other areas, morbidity rates for various diseases have been reduced dramatically, including meningococcal meningitis (93%), typhoid (75%), hepatitis B (52%), and tetanus (no cases since 1997). Preventive programs have also been strengthened for TB, leprosy, and some forms of hepatitis. Although deaths from infectious diseases have decreased greatly over the years, as a tropical island Cuba is still subject to various types of these diseases.
Prior to 1959, life expectancy in Cuba was below 60 years of age, infant mortality was over 60 (per 1000 live births), and there were 6,000 doctors and one medical faculty. Today, life expectancy is 76, infant mortality is 7 per 1000 live births, and there are 60,000 doctors and 22 medical faculties graduating 3,000 doctors per year. A major goal of the Cuban public health system has been free and accessible health care with an emphasis on preventive medicine through community involvement and international collaboration (1,500 Cuban doctors now work abroad in cooperative programs). Changes in medical training emphasize primary health care and direct contact with families and individuals and have resulted in public health improvements, both clinically and epidemiologically.
It was noted that the relationship between poverty and infectious disease that is so prevalent in many countries around the world (South Africa, for example) seems absent in Cuba. Participants wondered whether education is the most important factor in breaking the link between poverty and disease, or is there some other factor? One response emphasized that, in Cuba, the answer lies in combining the health system with a social system that:
- allows for more efficient and equitable distribution of limited and scarce resources,
- implemented literacy campaigns that allow citizens to make better use of public health information.
Vietnam was cited as another case where a country, under adverse conditions (the Vietnam war), was able to maintain high levels of public health. Primary health care is the best strategy for countering the effects of poverty on health. In particular, community based primary care is most important, whatever social system may be in existence. In Chile during the military government of the 1970s, strategies were developed for achieving 95 percent levels of hospital births. Despite having quite different social systems, Chile, Costa Rica and Cuba reportedly have the best vaccination rates and lowest incidence of disease in Latin America. In Cuba, vaccination levels for children under three years of age have reached 95% against most major diseases. It was pointed out that even wealthy countries like the US don’t have vaccination levels that can compare with Cuba and other developing countries.
Yet even countries like Chile that have positive health indicators (life expectancy, infant mortality) nonetheless have underlying problems with public health delivery. In part because of inadequate funding during the years of military government, there are discrepancies between the private and public health systems in terms of the quality of health care and the availability of various medical procedures. Moreover, where professionals and the upper class are disproportionately represented in the former, the lower classes and elderly are largely restricted to the public health system. Inequities can also be found in different parts of the country. Infant mortality rates vary widely, from 12 per 1000 live births in the major cities to 50/1000 or more in isolated mountain communities. The ratio of doctors to the general population also varies widely, with cities enjoying a per capita ratio four times that of rural towns and villages.
Participants from Cuba noted that, in coming years, a strengthened integrative approach involving hygiene and epidemiology is planned, involving national, regional, and municipal public health organizations. In general, the division of labor in public health in Cuba involves identification of priorities at the national level, the setting of priorities at the regional level, and the implementation of public health strategies at the municipal level.
In conclusion, participants agreed on the interaction of the three main components of an effective public health program: cost, access and quality. In terms of the first two criteria, Cuba has certainly been successful in providing basic health care benefits to its citizens at low cost. For example, spending in El Salvador is $100 per capita, in Cuba it is $130 per capita, yet health professionals in the former have little opportunity for participating in the planning and implementation of the health care system. Yet quality can be a subjective criterion, too often caught up in debates over cost cutting.
CUBA has a noteworthy record in reducing the incidence of communicable diseases, in comparison to both developing countries (where 33 percent of deaths are attributed to infectious diseases) and many developed countries. In coming years, Cuba will have to pay particular attention to the AIDS virus, as the country increases its relations to other countries and societies. It was reported there are 30 million people worldwide who are HIV positive, including many adults in Africa. Moreover, an AIDS vaccine is still doubtful, at least in the immediate future.
The World Health Organization (WHO) global monitoring and communications network will be especially important in coming years in identifying and grappling with as yet unknown viruses and communicable diseases. For example, while ‘mad cow’ disease is coming under control in the UK, other countries will have to be vigilant as the disease is able to spread easily through inexpensive (and infected) animal feed.
There are three WHO collaborative centers in Cuba, helping to monitor and report incidents of communicable diseases. One participant cautioned about Cuba being complacent regarding Dengue Hemorrhagic Fever, as there is a current outbreak in southeast Asia that has implications for other parts of the world. In particular, second and third stage infections are the more dangerous in Dengue Fever, where the symptoms are far more pronounced. In addition, the AIDS virus has led to an increase in other diseases such as TB, which needs to be closely monitored and controlled.
Mention was made of the threat posed by biological agents such as anthrax, in addition to a host of viruses and bacteria. A further example is smallpox, which has been eliminated but which could be reintroduced through bacteriological weapons. More dangerous at the moment are nerve gases including sarin.
Finally, malaria is still an important area of research, as two billion people (40 percent of the world’s population) in 100 countries remain at risk for various forms of malaria. Moreover, this type of research is particularly an area where developing countries and their scientific/medical R&D institutes can take a leading role.
There was also discussion of the importance of clean water, especially in those societies experiencing internal conflict. One participant noted the deficiencies often found in large and small scale irrigation systems, and pointed out that centralized water systems are especially vulnerable to direct attack and destruction. To avoid relying on large scale systems, new technologies are being developed that involve directional drilling to draw groundwater from rechargeable aquifers. The situation in Sri Lanka was noted, where municipal authorities in Kandy, the country’s second largest city, adopted some of these complementary portable water supply systems following the destruction of the Buddhist Temple of the Tooth in January 1998. These types of decentralized water supply systems could also improve public health and hygiene in under-developed countries where it is difficult to maintain large and expensive centralized water supply systems.
Natural and Homeopathic Medicines
EVERY country has a tradition of relying on natural medicines, particularly among farming communities and as a medical alternative for the poor. In Cuba, a national center for traditional and natural medicine was created in 1995 and made part of the Ministry of Public Health. Since then, efforts have been underway to integrate natural and traditional medicines and therapies (including acupuncture, ozone and magnetic treatments, relaxation techniques) into overall public health delivery. The production of natural products and medicines increased two and one half times between 1994 and 1997, and the emphasis now is as much on quality control as on total production. It was reported that, in 1998, almost three million patients in Cuba will be treated with natural and traditional medicines (18% of all patients), up from 850,000 patients in 1994.
What is needed, however, is continued scientific investigation into the effectiveness of such medicines, despite the difficulty of designing objective clinical trials. The problem is to transfer high quality medical research from the hospital to the community, where traditional and natural medicines are more likely to be used. One example cited was studies of the effects of natural therapies on the human nervous system being carried out in Cuba. For modern prescription medicines, there is a placebo effect of 30 percent, and that figure may well be higher for natural medicines, where the patient often feels a stronger sense of empowerment and control over his/her medical treatment. The Cuban Academy of Sciences has carried out studies on some 40 species of natural products in order to judge the effectiveness of various natural medicines, and it was thought that Cuba is well positioned to carry out additional research on natural medicines and therapies. But a concluding comment noted that seemingly effective natural medicines or therapies (e.g., placing an onion on a night table to treat a child’s night cough) should not be discounted just because they can not be scientifically evaluated. The point was also made that in a country like El Salvador, where the civil war devastated much of the country’s medical infrastructure, there was a necessary reliance for much of the population on traditional and natural medicines.
Cuban Public Health and the US Embargo
FOLLOWING the visit of Pope John Paul to Cuba in 1997, the US government indicated that it was willing to be more flexible in allowing the export of food and drugs to Cuba. But objections in the US, especially in Congress, were raised about possible diversion of these goods away from the people who need them. Questions were raised as well about the financial aspects of allowing more trade. The result has been a lack of progress in lifting parts of the embargo. In any event, the US government maintains that the embargo is not to blame for the lack of medicines; it’s Cuba’s lack of financial resources. A pharmaceutical trade fair in Cuba scheduled for January 1999 held out the promise of moving to a new phase, but those hopes were dampened when the necessary license for US participation was denied.
Other participants maintained there have been four major effects of the US embargo on the public health situation in Cuba, in the areas of nutrition, water quality, drugs, and medical information. The situation is particularly acute regarding third generation antibiotics, vaccines, steroids, and other expensive medicines. Being able to purchase such drugs from US suppliers would be a good deal less expensive (shipping costs especially) than from Europe and other more distant producers. A second major handicap is that of medical training, where Cubans are largely denied the opportunity for schooling and training in the US. A recent example of these constraints involved the cancellation of US-based training opportunities for Cubans who had been awarded scholarships by the WHO and the Pan American Health Organization.
One participant noted that opposition to the embargo by Americans rose from 51 to 56 percent following the Pope’s visit to Cuba in 1997. The reasons had less to do with the Pope than with the increased media coverage of Cuba, as Americans learned more about Cuba. Some participants felt that what is needed now is to marginalize the small political clique that keeps the embargo in place, in part through increased international and domestic pressure on the US government. For the medical community especially, the embargo prevents a physician from fully practicing his/her profession and carrying out the Hippocratic oath, thus violating the principles of the medical profession.
[Editor’s Note: In October 1998, shortly after the Pugwash workshop, a group of senior American policy figures, including former secretaries of State Henry Kissinger and George Schultz, were calling for a bipartisan national commission to fundamentally re-evaluate US policy toward Cuba.]
The Optic Neuropathy Epidemic in Cuba
IN 1992-93, Cuba experienced an epidemic of optic neuropathy (degeneration of the optic nerve) that ultimately affected more than 45,000 people (425 per 100,000). The search for causes of the rapid spread of both optic and peripheral neuropathy ruled out the existence of an infectious disease or possible toxic causes (food, water, pesticides). Treatment with vitamins proved successful, pointing to nutritional causes. Changes in diet in the early 1990s, partly a result of both the loss of Soviet aid and the US embargo, had resulted in reduced consumption of meat, diary products, breads, fats, cereals, and coffee. The average Cuban diet thus consisted mainly of rice, beans, cabbage, cassava, and herbal teas, with sugar added to meals and drinking water to increase calorie intake. In addition, a high percentage of smokers were affected (93 percent), as low levels of B12 and B6 which usually break down the cyanide and other toxins found in cigar and cigarette smoke are not present. The result is a “nutritional toxic” insult. It was noted that this disease has also been common to POWs and was evident in Cuba during the Spanish-American War (when there was also an American embargo).
Currently, there is a network of diagnostic centers to monitor and detect possible new levels of optic neuropathy. It was pointed out that lack of medical diagnostic resources has also been one consequence of the US embargo.
Yet the international collaboration that helped solve the optic neuropathy problem was also the first example of bilateral governmental cooperation between Cuba and the US (the Centers for Disease Control) on a public health issue. The value of such international cooperation was summed up for a Cuban physician by a Nobel laureate who said of the optic neuropathy experience: “there’s good news and bad news about the epidemic. The good news is that the disease probably won’t come back. The bad news is, you may never know exactly what hit you.” Thus, this type of international cooperation and dissemination of information is especially valuable as the disease could well occur elsewhere, with little warning.
Questions were asked about the absence of optic neuropathy in other countries suffering nutritional deficits. The response was that the important variable in Cuba (as among POWs) was the sharp drop in vitamin intake and change in diet in 1992-93, not just the vitamin deficit per se.
International Public Health Cooperation
ONE presentation listed six central elements of international public health. In addition to normal peacetime, social and economic development components, these now include war and conflict, human rights, gender, equity and information technology dimensions. In recommending additional research on public health issues, emphasis was placed on epidemiology research and training; more research on war, conflict and social unrest (emergency relief); information technology; use of local nationals; and international and cross-cultural efforts to develop new public health strategies.
In the case of South Africa, there has only recently been an effort to construct a public health network that goes beyond university-based programs and the minimal services previously available under apartheid. One example of international cooperation is the assistance provided by 600 Cuban doctors working in South Africa to help increase access to public health. Conversely, South African students receive public health training in Cuba (at far less cost than it would be in the US or Europe). The National School of Public Health in South Africa has formed cooperative programs with Hebrew University (Jerusalem) and George Washington University (Washington, DC), but linking with programs in other developing countries is proving difficult.
A recent Israeli-Colombian study identified family medicine physicians as the cornerstone of both comprehensive and preventive care. Workshop participants pointed out the importance of national differences, however. For example, family doctors in the UK have about 1600 patients, while Cuban doctors have 300 patients, and there’s a difference between family doctors who are primarily clinicians and those who are primarily public health doctors.
Finally, the discussion of public health delivery in Israel included issues of policy choices facing societies and governments. For example, childhood diarrhea kills one million children a year around the world. The rotavirus vaccine has been developed that, while not preventing diarrhea, greatly reduces mortality. This vaccine is, however, very expensive. At $38 a dose, $1.48 billion (about the cost of one nuclear submarine) would be needed to treat 13 million children aged six months or less. These are the kind of trade-offs facing both national governments and the international community.
Medical Information Technologies
FOR a number of years, public health specialists in Cuba have sought to make increased use of new communications and information technologies (email, websites, cd-rom) to disseminate information to public health doctors and specialists throughout Cuba, even to remote regions of the country. In 1995, the United Nations provided initial support for the Cuban Infomed program (www.igc.apc/cubasol). An Infomed assistance program in US has provided 800 computers since then, and this group is lobbying the US Congress in support of the Torres bill which would exempt drugs and medicines from the US embargo.
Participants were also briefed about the CARDIOnet program headquartered in Zagreb, Croatia. CARDIOnet is an international education program in cardiovascular medicine on the internet (www.cardionet.hr). It is aimed mainly at cardiologists and public health specialists in countries lacking continuing organized education, and it currently operates in 56 countries with 9,000 registered physicians.
With full access to the internet, Cuban public health specialists could access the WHO website and others from around the world.
Public Health and Child Abuse
CURRENT thinking about child abuse is informed by issues of quality of life, equity, and sustainable development. Previous milestones in this area include the Universal Declaration of Human Rights (1959) and the Convention on Children’s Rights (1989). Today, other variables have to be integrated as well, including illiteracy, economic status, degradation of the environment, and violence. In particular, economic deprivation and environmental degradation can produce severe strains in social relations. Regarding population pressures, it was noted that in Latin America from 1970-90, urban population increased by a factor of three (42 to 116), while rural population remained fairly constant (71 to 80).
Regarding child abuse, both the family and the state have important roles to play, the state in setting norms for social relations, the environment, and sustainable development. Participants noted the importance of setting child abuse and neglect in a wider context, one that fits well with the Pugwash agenda on broader social issues of peace and war, development and poverty.
One participant looked at the issue of child abuse/child neglect in the context of free market v. communitarian societies, with the latter putting more value on children as societal investments. For example, the focus of research should perhaps be less on infant mortality rates per se (7 per 1000 live births in Cuba), but on the remaining 993 babies who live. What is happening with the birth weight of these babies, the health of the mother, etc.? These are the issues that are ultimately more important for society as a whole and for the future of the country. As an example of this point in the UK and US, causes of mortality for upper and lower income groups are roughly the same, but poorer people die earlier, often because they were less healthy as children. In addition, there needs to be more research on the effects of the embargo on health indicators.
Pugwash and Public Health
THE concluding discussion focused on the possibility of Pugwash becoming more involved in public health issues. Given the many interests within Pugwash, and with limited resources, what particular areas should it concentrate on? In terms of possible future Pugwash activities, the point was made that Pugwash has a comparative advantage of looking at public health issues in the context of war and peace. Two examples would be the health consequences of new weapons (conventional, chemical, and biological weapons) and the social and health effects of intra-state violence.
International Pugwash would like to thank the Cuban Pugwash Group and Prof. Maria Elena Montero Cabrera for their help in organizing the workshop. International Pugwash also gratefully acknowledges support from the Christopher Reynolds Foundation, the Arca Foundation, the Samuel Rubin Foundation, and the John D. and Catherine T. MacArthur Foundation.