Care of Common Endocrine Problems in Cuba

Beatriz Rodriguez Olson and Richard A. Dickey

Department of Medicine (B.R.O.), Yale University, New Haven, Connecticut 06510; and School of Medicine (R.A.D.), Wake Forest University, Winston-Salem, North Carolina 27157

Address all correspondence and requests for reprints to: Beatriz R. Olson, M.D., F.A.C.P., Endocrinology and Metabolism, 850 Straits Turnpike, Suite 204, Middlebury, Connecticut 06762. E-mail: beatrizmd{at}snet.net.


    Introduction
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
This discussion of the treatment of common endocrine conditions in Cuba is based on information gathered in discussions held with eight endocrinology professors from the National Institutes of Endocrinology and Metabolism (NIEMH) in Habana and with physicians at other facilities during several meetings of our People-to-People Ambassador endocrinology delegation held in the provinces of Habana and Trinidad in Cuba on December 8–15, 2001. Information obtained was subsequently verified through review of published Cuban endocrinology literature and public health statistics from 1995–2002. This manuscript shows the importance of economic status in a country with modern medicine.


    Medical facilities/education
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
Cuba is respected throughout Central and Latin America as a leader in medical education. These countries send their best students to receive their medical education in Cuba (personal communication, Dr. Oscar Diaz Diaz, Endocrinology Epidemiology, Director of the NIEMH). There are 13 medical schools in Cuba. The number of medical graduates per year for the past 7 yr ranges from 3255–1765 (www. dne.sld.cu/desplegables/cuba1997.htm, www.dne.sld.cu/desplegables/cuba1998.htm, www.dne.sld.cu/desplegables/cuba1999.htm, www.dne.sld.cu/desplegables/cuba2000.htm, www.dne.sld.cu/desplegables/cuba2001.htm). Cuba’s population of 11 million people is served by 267 hospitals, 444 polyclinics, and 21 medical academic faculty centers (www.dne.sld.cu/desplegables/cuba2001.htm).


    Levels of care
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
The approach to patient care in Cuba is through the use of three levels of access to health care. In each Cuban community of approximately 100 families, a primary care doctor, usually a recent medical graduate, provides the first level (level I) of medical care. This physician, with access to medical supplies and drugs for treatment of common routine ailments, is to know and counsel families; to detect patients with significant disease(s) that require referral to specialists; to provide education and preventive health care; and to ascertain that patients follow through with mandated health screening and health policy. Cuban published statistics note that 99.1% of their population is attended by medical doctors (www.dne.sld.cu/desplegables/cuba2001.htm).

Access to the second level of care is provided by the polyclinics, which are smaller hospital facilities, in each province where specialists provide specialized care and have greater access to medications. Access to the third level of care is at the university hospitals of each of the 14 Cuban provinces and at the Cuban National Institutes of Health in Habana, where teaching and research takes place. Here the physicians have access to medication deemed essential for the survival of the patient, medications otherwise relatively unavailable.


    Diabetes mellitus
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
The top three causes of death for the Cuban population are heart disease, cancer, and cerebrovascular disease, respectively. We were told that diabetes is the eighth cause of death in Cuba (personal communication, Dr. Rolando Suarez Perez, Division of Diabetes/Education, NIEMH). Our literature search suggests that the incidence of death due to diabetes has decreased from 1997–2001, from 18.4 to 10.4 per 100,000 people aged 1–60 yr, and that diabetes is now the ninth greatest cause of death in Cuba (www.dne.sld.cu/desplegables/cuba1997.htm, www.dne.sld.cu/desplegables/cuba1998.htm, www.dne.sld.cu/desplegables/cuba1999.htm, www.dne.sld.cu/desplegables/cuba2000.htm, www.dne.sld.cu/desplegables/cuba2001.htm, http://www.sld.cu/anuario/anu01/cmt5.htm). There are almost twice as many deaths in women as in men with diabetes (Ref.1 and www.dne.sld.cu/desplegables/cuba2001.htm). Deaths from diabetes are highest in areas of high concentrations of elderly patients, such as the central Habana municipality, which has death rates of 214.6 per 100,000 inhabitants (1).

Dr. Rolando Suarez Perez informed us that diabetes has a prevalence of 3% (10% type 1), but an additional 3% of Cubans with diabetes are thought to be undiagnosed. Epidemiological studies suggest a diabetes prevalence of 5% (1). Type 1 patients are treated in level II and III facilities where they have access to insulin. Glybenclamide was the only sulfonylurea available for the treatment of type 2 diabetes; neither metformin nor glitazones are available due to expense. Countries importing medicines to Cuba violate the U.S. embargo against Cuba and face fines and restrictions on trade with the United States for the next 6 months. Cubans typically do not monitor their glucose because glucometers and glucose strips are expensive and unavailable. Patients whose lives depend on the use of insulin are identified. Insulin-dependent patients receive neutral protamine Hagedorn or Lente at night and three injections of regular insulin during the day. Glycosylated hemoglobin (type of assay used was not discussed) is not routinely measured except in type 1 patients. We were told that average glycosylated hemoglobin is 8% at level II and 7% at level III facilities, i.e. average glucose was better with specialist care/higher levels of care (personal communication, Dr. Rolando Suarez Perez). This personal communication could not be verified by published literature.

The population of Cuba has grown by one quarter million in the last 5 yr (www.dne.sld.cu/desplegables/cuba1997.htm, www.dne.sld.cu/desplegables/cuba1998.htm, www.dne.sld.cu/desplegables/cuba1999.htm, www.dne.sld.cu/desplegables/cuba2000.htm, www.dne.sld.cu/desplegables/cuba2001.htm), and we were told the incidence of diabetes is increasing because of a growing and aging population. Indeed a recent document published by the Ministry of Public Health in Cuba states that the incidence of diabetes in Cuba is now 17% and the incidence of hypertension is now 30% (2). Insight on the care of hypertensive, diabetic patients was obtained from data published on 683 type 2 diabetic patients cared for at a polyclinic (level II facility) with 1400 diabetics. Hypertension was defined as blood pressure above 130/90 mm Hg. They noted that in 311 normotensive patients (19% insulin users), the mean microalbumin excretion was 159.2 ± 111.7 mg/liter. In contrast, in the 372 hypertensive patients (29.3% insulin users), the mean microalbumin excretion was 269.4 ± 171 mg/liter. Monotherapy was the predominant mode of treatment including a low-sodium diet, diuretics, and calcium channel blockers. A minority of 1% used angiotensin receptor or angiotensin-converting enzyme inhibitors. A total of 12.9% used all therapies. With a criteria for good control being a systolic blood pressure below 130 mm Hg and a diastolic blood pressure below 85 mm Hg, 62.3% of patients had good control, 25.8% had poor control, and 8.6% were not treated. These investigators noted that a waist-to-hip ratio more than 0.9 was more common in patients with hypertension. Similarly, nephropathy with or without coronary artery disease and retinopathy predominated in patients with hypertension (3).

Each of the 14 Cuban provinces has a third level hospital for renal transplantation and photocoagulation for diabetic retinopathy. Recently, pancreas transplantations were being done with renal transplantation, using the Edmonton protocol (personal communication, Dr. Oscar Diaz Diaz).

Certain patients with metabolic disorders, who were under relatively good control, were referred to the Kurhotel, a rehabilitation facility we visited in the mountains of central Cuba at Escambray. Here, an integrative therapeutic approach is used. For example, painful diabetic neuropathy is treated using an herb, called albaca morada, administered as a tea, intramuscular B complex injections, magnet therapy, and the tricyclic antidepressant amitriptyline at a low dose (12.5 mg twice a day), and, if necessary, carbamazepine (Tegretol) [personal communication from physicians at Kurhotel, Dr. Tania Perez Cardenas (Internist and Assistant Director of Kurhotel), Dr. Antonio Hernandez Morales (Endocrinology fellow on rotation), and Licenciada Sonalli Sanchez Reyes, (pharmacist with a special interest in botanicals, Laboratorio de Plantas Medicinales)]. It was unclear to us how patients are selected for treatment at the Kurhotel and whether there was a long waiting list. Data on the long-term outcome of patients who undergo this treatment were not available and were not currently part of research efforts.

The endocrinologists in Cuba are aware of hyperinsulinism and the metabolic syndrome; however, to date there are no data published on the prevalence of these conditions in Cuba (4). We found a prospective study that followed, for 18 yr, patients identified as glucose intolerant. Of these, 53.6% evolved to diabetes mellitus, 23.8% had impaired glucose tolerance, and 22.6% were normal (5).

We were informed that obesity is not a problem in Cuba (personal communication, Dr. Rolando Suarez Perez). We hypothesized this may be due to nutritional and physical activity differences in the Cuban environment. We observed that Cubans walk or bicycle to most places, largely because fuel for transportation in Cuba is not plentiful and is expensive. One recent Cuban review article on obesity notes this condition as a world problem (6). Statistics on the incidence of obesity or morbidity associated with obesity for Cubans are not available in the Cuban literature, and importantly obesity is not listed as a health problem in any of the annual health statistics publications (http://www.sld.cu/servicios/estadisticas/ and www.dne.sld.cu/desplegables/cuba1998.htm, www.dne.sld.cu/desplegables/cuba1999.htm, www.dne.sld.cu/desplegables/cuba2000.htm, and www.dne.sld.cu/desplegables/cuba2001.htm). A report on a World Health Organization (WHO) consultation on obesity held in Geneva in 1997, published by the WHO, notes that 37% of Cubans have a body mass index (BMI) above 25, 55% have a BMI of 18.4–25, 7% have a BMI of 18.4–16, and less than 1% have a BMI below 16 (7).


    Thyroid disease
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
Thyroid disease is common. Since 1986 Cubans have had a neonatal program for detection of congenital hypothyroidism. A sensitive TSH assay was not available in Cuba due to lack of finances and the U.S.-imposed "blockade" (the term used by Cubans to describe the U.S. trade embargo against Cuba) so they developed their own ultramicroELISA that uses the SUMA (Cuban patent) ultramicroanalytic system (8, 9). At the Cuban NIEMH, 160 TSH assays were being done per week. The normal range of this immunoradiometric assay TSH assay is 0.3–3.5 IU/liter. Hypothyroidism and hyperthyroidism were defined as a TSH value above 3.5 and below 0.3 IU/liter, respectively.

The Cubans could measure thyroid peroxidase antibody and thyroglobulin antibody (type of assays not discussed) and recently have had an increasing interest in studying the prevalence of postpartum thyroiditis. They use a thyroglobulin assay to monitor patients with thyroid cancer and had recently sent the head of the thyroid laboratory abroad to study the thyroid-stimulating Ig assay.

Goiter (bocio) and nodular (bocio nodular) thyroid disease are common in Cuba, and this is thought to be due to iodine deficiency (personal communication, Dr. Alavez Martin, senior professor of the Thyroid Diseases Section, NIEMH). Although we could not specifically verify this statement, we did find documentation that Cuba has been identified along with 17 other Latin American Countries by the WHO as a country where iodine (yodo) deficiency is a health problem. As of 1999, Cuba had not yet documented to WHO that the problem had been resolved (10). Diffuse goiter is selectively treated with TSH-suppressive doses of L-T4 in patients younger than 30 yr, and in those with goitrous enlargement of less than 1 yr, where the benefit of treatment is detectable after 1 yr. Cubans have not found the benefit of TSH-suppressive doses for other groups or with treatment longer than 5 yr. This practice was based on their own retrospective study of patients with diffuse goiter treated from 1970–1990 (11). Thyroid nodules, once detected, are referred to the thyroid specialty team of the province. Thyroid biopsies are done for all thyroid nodules that were found, and colloid nodules were treated with an ethanol injection. Over the years, Cuban thyroidologists have made a considerable effort to document the best method for fine-needle aspiration, and none of the methods involve ultrasound-guided biopsy (12, 13, 14). The studies by Alavez et al. (13) quote fine-needle cytopuncture with aspiration diagnostic sensitivity of 83% and specificity of 100%, and those of Ochoa Torrez (14) show diagnostic sensitivity of 76% and specificity of 85% when cytopuncture is done without aspiration.

Review of data published by La Direccion Nacional de Estadisticas del Ministerio de Salud Publica de Cuba (data from the National Cancer Registry for 2002 morbidity) show that thyroid cancer is listed as one of the top 10 types of cancer that afflict Cuban women aged 15–60+ yr, with an incidence of 7.1 per 100,000 after breast, skin, lung, colon, cervical, and endometrial malignancies [http://www.sld.cu/servicios/estadisticas/, http://www.sld.cu/anuario/anu01/morbilidad.html, http://www.sld.cu/anuario/anu01/cmb7a.htm (searches for morbidity and mortality, 1999–2002, for women and men aged 15+ yr)]. Thyroid cancer incidence is not listed as one of the top 10 cancers for men in morbidity statistics [http://www.sld.cu/servicios/estadisticas/, http://www.sld.cu/anuario/anu01/morbilidad.html, http://www.sld.cu/anuario/anu01/cmb7a.htm (searches for morbidity and mortality, 1999–2002, for women and men aged 15+ yr)]. Mortality from thyroid cancer is not listed, as it is not one of the top 15 causes of cancer deaths for Cubans. Thyroid cancer is treated with total thyroidectomy and 131I ablation of remnant tissue. Frozen sections are not felt to be useful in helping decision-making during surgery (13). A small retrospective review of gestation in 24 women previously treated for differentiated thyroid cancer gives insight into the typical treatment of patients diagnosed with differentiated thyroid cancers. Doses of 131I ranging from 2.5–3.70 GBq were given (average of 4.16 + 1.66 GBq; an outlier received 7.40 GBq; 1 GBq = 27 mCi). TSH suppression was achieved with a daily dose of either 180 mg desiccated thyroid or 150 µg thyroxine sodium salt. Although the time of gestation was delayed in these women, no adverse outcome was found from having received 131I for thyroid cancer treatment (15). Recombinant TSH (Thyrogen, Genzyme, Cambridge, MA) is not available in Cuba so patients undergo thyroid hormone withdrawal before 131I whole body diagnostic scanning to assess for disease recurrences and metastasis. Cuban thyroidologists are studying the efficacy of hemilobectomy for patients with unilateral, small papillary thyroid cancers (personal communication, Dr. Alavez Martin). Patients with hyperthyroidism due to Grave’s disease are typically treated with propythiouracil; methimazole (Tapazole, Eli Lilly, Indianapolis, IN) is not available in Cuba (personal communication, Dr. Antonio Hernandez Morales). Hypothyroidism is treated with L-T4 (personal communication, Dr. Alavez Martin).


    Osteoporosis
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
Children in Cuba have a quota of milk available to them until age 7; children between the ages of 7 and 12 yr are entitled to yogurt. After the age of 12, milk and yogurt are not readily available. The problem is economic. One quart of milk costs 42 pesos (about $1.60) yet the average Cuban worker earns only 200 pesos per month. Calcium is limited in the diet of the average adult Cuban. This information was received from numerous academic and nonacademic sources.

Based on studies done in the Unite States, Cubans understand that the epidemics of the developed world are diabetes, obesity, and osteoporosis. The prevalence of osteoporosis in Cuba is not known. However, Cubans believe that Cuba will face this problem. If they assume that the same percentage (as in developed countries) of aging Cuban people are affected with osteoporosis, then 558,750 women older than 65 yr, 375,000 postmenopausal women between the ages of 50 and 65 yr, and 375,000 men older than 50 yr are assumed to have the disease (16). We were able to find two publications documenting osteoporosis in elderly Cubans (17, 18). Ochoa Torres and Pereira Costa (18) screened one of six elderly Cubans scheduled for routine medical screenings using radiographs. Of 67 women and 21 men between the ages of 65 and 89 yr tested, 100% of the patients screened had osteoporosis by x-ray criteria, and 19% had radiologic fractures. Of these, 18% were in women and 24% were in men. The authors comment on the large prevalence of this condition despite the warm, sunny climate of Cuba and individuals with darker skin (18). Osteoporosis is diagnosed only by plain-film x-rays so it requires a 30% bone mass loss for detection of disease. There were no dual-energy x-ray absorptiometry machines in Cuba.

Estrogens, not readily available, were only administered in severely osteoporotic women or for those with bone fragility-related fractures (personal communications, Dr. Daysi Navarro Despagne, Clinical Services, Women’s Health, NIEMH, and Dr. Rolando Suarez Perez). They were just beginning to use estrogens to prevent fractures. Bisphosphonates and selective estrogen receptor modulators were unavailable, and calcium preparations are not readily available. The potential for underidentification and treatment of osteoporosis in Cuba, for economic reasons, is huge. In America, there is also underidentification and undertreatment of conditions of low bone mass, but not because we lack the methods of detection (19, 20).


    Other calcium disorders
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
In the United States we detected a higher incidence of hypercalcemia and hyperparathyroidism after the automation of chemistry panels and the measurement of serum calcium in these panels. In Cuba calcium is not routinely measured (personal communication, Dr. Rolando Suarez Perez). This may be why Cubans believe there is a relatively low incidence of clinically significant hypercalcemia and hyperparathyroidism in Cuba.


    The climacteric and menopause
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
Two studies suggest that age of onset of menopause in Cuba is on average 48 yr, earlier than has been found in other developed countries (21, 22). Cubans consider menopause, perimenopause, or the climacteric as non-life-threatening processes and therefore do not spend their limited funds for the study and treatment of these women’s issues. With limited funding, the Cuban physician finds the choice of providing insulin for the patient with type 1 diabetes or hormone replacement therapy (HRT) for the woman with menopause or osteoporosis easy. Furthermore, limiting provision of estrogens is the fact that HRT can only be prescribed by level III physicians for very symptomatic (vasomotor) or severely osteoporotic women (personal communication, Dr. Daysi Navarro Despagne, Clinical Services, Women’s Health, NIEMH).

The practice of limiting HRT to the most symptomatic women and the use of alternative therapies for menopause is supported by a number of Cuban-based studies. First, a small study of 25 women treated with HRT for severe menopausal symptoms showed that vasomotor symptoms improved in all women, whereas only 30% showed improvement of nonvasomotor symptoms (23). Second, it is concluded that Cuban women are driven by social rather than biological factors when choosing to take HRT. This is based on a survey of 320 Cuban women ages 40–59 yr, 70% of whom were experiencing menopausal symptoms, showing that 41% of women were willing to receive therapy for symptoms; of these, only 30% were willing to try HRT, and only 2.18% (seven women) had actually received HRT. Of these seven women, four abandoned therapy due to lack of medicine or fear of cancer. Women had received information about HRT from their doctor (27%) and from nonmedical sources (73%) (24). Third, there is the belief that menopausal symptoms may be treated by plant-derived phytoestrogens and herbs like salvia de Castilla, which can relieve the frequency and intensity of hot flushes (bochornos) by 72% in 62 peri- or early menopausal women evaluated over the 6- to 12-wk trial period (25). In addition to herbals and phytoestrogens, vasomotor symptoms of menopause were also treated with acupuncture, exercise, and yoga. Nonetheless, Dr. Navarro Despagne, the primary investigator of many of the women’s studies, notes that more research needs to be done on the therapies they are using, and wishes a wider range of allopathic/medical therapies were available.

The importance of women in the Cuban society may, in time, become a factor that causes Cubans to address more seriously women’s health as a priority. Cuba has a growing population of women entering midlife—women who are equivalent to men as wage earners in the workforce but who, in addition, run the home, cook every night, take care of the children, and are responsible for the social and economic stability of the society. Thus, health problems that are long-standing and contribute to disabilities will affect this generation of women and may well have a significant impact on Cuba socially and economically (personal communication, Dr. Daysi Navarro Despagne).


    Hyperlipidemias
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
In Cuba, lipid disorders are treated primarily with diet, exercise, and an herbal tea using pepeje, a polysaturated alcohol from the genus Ocimun. Physicians in Cuba feel that this improves glycemic control by increasing insulin sensitivity and improves hypertension (personal communcation of Dr. Tania Perez Cardenas, Dr. Antonio Hernandez Morales, and Licenciada Sonalli Sanchez Reyes). No medications (e.g. 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) are available for dyslipidemia (information gathered from numerous physicians). Patient adherence to diet and exercise for the treatment of lipid disorders is as much of a problem in Cuba as in the United States (personal communication, Dr. Rolando Suarez Perez).


    Botanicals replace unavailable medicines
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
Botanicals grown in Cuba are regulated. Recommendations are made to pharmacists on how to compound these and how botanicals are to be administered for specific medical conditions. Botanicals used are grown in the country and compounded to be used as medicines. The costs for outcome-measures studies about the efficacy of the botanical pharmacopea have obviated such studies (personal communication, Licenciada Sonalli Sanchez Reyes).


    Summary
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 
Endocrine care in Cuba is limited and is said to be impacted by the U.S. trade embargo. At the local level, each level I physician cares for 100 families, helping toreinforce preventive health habits and detecting the very ill who may benefit from higher level (II and II) treatment and access to medications available only at those levels. Priority of care and resources are directed to life-threatening illnesses or diseases for which funds are available through support from non-Cuban sources (e.g. WHO). Care for disorders or disease of less current concern to the Cubans such as loss of bone mass and osteoporosis, menopause, or undetected hypercalcemia are not being adequately addressed at this time.

Although Cubans point out that they have a system of universal health care, that care, especially access to medications, is limited due to several economic and political factors, including the U.S. trade embargo. In our interactions with the Academic Cuban Endocrinology Community, and in conducting our research on published Cuban endocrine literature, we found that lack of resources to provide state-of-the-art care did not preclude a high level of knowledge and scholarship. These individuals have access to the latest journals through the Internet, and they use these resources to teach, do their own research, and write review articles that are used to teach and train physicians within and outside Cuba.


    Acknowledgments
 
We acknowledge with gratitude the many Cuban colleagues with whom we met. These health care workers clearly have an immense drive to help their fellow Cubans with their health care needs despite all the limitations they face. The Cubans have an incredible desire to advance their personal and professional lives, their education, and their culture. We especially appreciated our open professional interaction with the academic endocrinologists of the NIEMH: Dr. Daysi Navarro Despagne (Clinical Services, Women’s Health), Dr. Rolando Suarez Perez (Diabetes/Education), Dr. Francisco Carvajal Perez (Pediatric Endocrinology), Dr. Jose Mesa (Public Health and Diabetes), Dr. Eduardo Cabrera-Rodes (Genetics and Immunology), Dr. Alavez Martin (Thyroid Disease), Dr. Santana (Research in Reproductive Endocrinology), and Dr. Oscar Diaz Diaz (Endocrinology Epidemiology and Director of the NIEMH); with the physicians and professional staff of Kurhotel, Topez de Collantes, Escambray, Trinidad, Cuba, a large rehabilitation facility located in a remote location in the mountains of central Cuba: Dr. Tania Perez Cardenas (Internist and Assistant Director), Dr. Antonio Hernandez Morales (Endocrinology fellow), and Licenciada Sonalli Sanchez Reyes (Pharmacist with a special interest in botanicals, Laboratorio de Plantas Medicinales), and other health care professionals in Cuba, including Dr. Rodolfo Stusser (Habana Polyclinic).


    Footnotes
 
Abbreviations: BMI, Body mass index; HRT, hormone replacement therapy.

Received August 5, 2003.

Accepted January 18, 2004.


    References
 Top
 Introduction
 Medical facilities/education
 Levels of care
 Diabetes mellitus
 Thyroid disease
 Osteoporosis
 Other calcium disorders
 The climacteric and menopause
 Hyperlipidemias
 Botanicals replace unavailable...
 Summary
 References
 

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