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.
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Introduction |
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Medical facilities/education |
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Levels of care |
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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.
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Diabetes mellitus |
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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 18.425, 7% have a BMI of 18.416, and less than 1% have a BMI below 16 (7).
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Thyroid disease |
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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 19701990 (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 1560+ 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, 19992002, 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, 19992002, 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 2.53.70 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 Graves 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).
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Osteoporosis |
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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, Womens 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).
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Other calcium disorders |
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The climacteric and menopause |
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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 4059 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 womens 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 womens health as a priority. Cuba has a growing population of women entering midlifewomen 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).
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Hyperlipidemias |
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Botanicals replace unavailable medicines |
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Summary |
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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.
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Acknowledgments |
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Footnotes |
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Received August 5, 2003.
Accepted January 18, 2004.
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References |
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