- Email: [email protected]
Health in Cuba: the other side of the story
Correspondence
For the InterAcademy Medical Panel statement see http:// www.iamp-online.org/ statements For more on Black Spring see http://en.wikipedia.org/wiki/ Black_Spring_%28Cuba%29
See Comment Lancet 2013; 382: 192
944
These numbers, concerning as they are, also hide another important factor. A disproportionate number of people struggle with the effects of hearing loss in low-income and middle-income countries. In wealthy countries, people generally have access to specialist medical care and can afford costly devices such as hearing aids and cochlear implants. In most developing countries, access to even the simplest of routine checks or hearing aid devices is scarce. Despite the fact that many of the causes of hearing loss can be identified and remedied, millions of people with hearing loss still live less than fulfilling lives, with associated detrimental effects on their families and wider society. For this reason, on March 3—International Ear Care Day—the InterAcademy Medical Panel (IAMP) releases its latest statement: A Call for Action to Strengthen Healthcare for Hearing Loss. IAMP represents 73 academies of medicine and medical branches of science academies worldwide, and among its objectives is provision of evidence-based advice to governments for health and science policy. The IAMP statement calls on governments and health-care providers: to implement improvements to health-care provision for hearing loss, such as universal hearing screening in birthing centres and improved affordability and accessibility of cochlear implantation; to implement policies to ensure that public health measures account for the causes of hearing loss; to address hearing loss in both children and adults while the differences between these groups are also acknowledged; to address broader societal needs, such as provision of educational programmes for children with hearing loss, their relatives, and communities; and to establish research and innovation programmes targeted at hearing loss priorities, including development of novel screening and diagnostic techniques to improve early identification of hearing loss in children and development of
affordable high-quality hearing aids and low-cost batteries. Despite being a common cause of functional and cognitive problems— and a major global health challenge— hearing loss is often preventable and avoidable. The time has come to rally around the key areas highlighted in the IAMP statement in a global, concerted, and sustained effort to improve the lives of all people with hearing loss. We declare no competing interests.
Lai Meng Looi, Detlev Ganten, *Peter F McGrath, Manfred Gross, George E Griffin [email protected] Academy of Sciences Malaysia, Kuala Lumpur, Malaysia (LML); German National Academy of Sciences Leopoldina, Berlin, Germany (DG); InterAcademy Medical Panel, Trieste 334151, Italy (PFMcG); Deparment of Audiology and Phoniatrics, Charité—Universitätsmedizin, Berlin, Germany (MG); and Deparments of Infectious Diseases and Medicine, St George’s, University of London, London, UK (GEG) 1
2
3
4
WHO. Millions of people in the world have hearing loss that can be treated or prevented. Geneva: World Health Organization, 2013. Lin FR, Thorpe R, Gordon-Salant S, Ferrucci L. Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci 2011; 66: 582–90. Gallacher J, Ilubaera V, Ben-Shlomo Y, et al. Auditory threshold, phonologic demand, and incident dementia. Neurology 2012; 79: 1583–90. Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol 2011; 68: 214–20.
Health in Cuba: the other side of the story In the past years, The Lancet has published Editorials and Comments in support of the public health situation in Cuba, without taking into consideration the country’s political situation. The Editors did this again in their recent Editorial (Jan 3, p 2),1 in which they support the re-establishment of diplomatic ties between Cuba and the USA on the matter of public health. However, Cubans live under a totalitarian regime that has silenced dissent, imprisoned,
and killed opposition leaders. 2 Persecution of dissidents continues today, as exemplified by the recent arrest of artist Tania Bruguera. In the public health arena we cannot forget the human-rights violations of patients with HIV/AIDS in the late 1980s and early 1990s, when HIV/AIDS tests were mandatory in Cuba, and people who tested positive were incarcerated in sanatoriums described by Jonathan Mann as “pretty prisons”.3 As stated in the Lancet Editorial,1 universal access to health care and education is a great accomplishment and a source of pride for the Cuban population. However, that same pride is eroded by a government that punishes the creativity of the Cuban population and limits the exercise of civil liberties. In 2003, during what is called Black Spring two economists were condemned to prison while documenting that public health and education in Cuba were already among the best in Latin America before the Revolution. In 1958, the infant mortality rate was 33 per 1000 livebirths, far lower than that of Argentina (61), Costa Rica (89) and Mexico (80).4 The Cuban Government sends doctors and nurses to work in Venezuela and Brazil for meagre salaries and retains most of their income.5 To use public health as a leading topic of the re-establishment of diplomatic relations between the USA and Cuba is a good idea, as your Editorial 1 and Anthony Robbins’ letter6 to The Lancet suggest. But there is another major opportunity: the positive effect of democracy on public health has been well documented. If the Cuban Government is so concerned about the health of its population, it could seriously consider a transition to democracy as part of the conditions for a new relation with the USA, not only for the sake of liberty, but also for the sake of the health of the Cuban population. I declare no competing interests.
www.thelancet.com Vol 385 March 14, 2015
Correspondence
Octavio Gómez-Dantés [email protected] National Institute of Public Health, Health Systems, 6210 Cuernavaca, Morelos, Mexico 1 2
3
4
5 6
The Lancet. Cuba: health lessons not under embargo. Lancet 2015; 385: 2. Human Rights Watch. Cuba´s repressive machinery. Human rights forty years after the revolution. http://www.hrw.org/reports/1999/ cuba (accessed Feb 12, 2015). McNeil DG. Cuba´s fortress against a viral foe. New York Times (New York), May 7, 2012. http:// www.nytimes.com/2012/05/08/health/cubasaids-sanitariums-fortresses-against-a-viral-foe. html (accessed Feb 12, 2015). Sixto FE. An evaluation of four decades of Cuban healthcare. http://www.ascecuba.org/c/wpcontent/uploads/2014/09/v12-sixto.pdf (accessed Feb 12, 2015). Devi S. Cuba’s economic reforms prompt debate about health care. Lancet 2014; 383: 294–95. Robbins A. Cuba–US relations: will public health lead the way? Lancet 2015; 385: e3.
Cuba–US collaboration and the role of bioethics For more than a half century, official relations between Cuba and the USA have been tense, fraught, and shaped by a mistrust which has not served the interests of ordinary Cubans or Americans. Despite official policies, some of those ordinary citizens— scholars, scientists, artists, and others—have forged ties based on mutual goals and objectives. One good example consists in apolitical efforts by the two countries’ bioethics communities, elements of which have hosted conferences, scholarly visits, and curriculum development projects. Topics have ranged from brain death to public health. For instance, the University of Miami Bioethics Program, the Research Ethics Committee of the Centre of Hygiene, Epidemiology and Microbiology in Matanzas City, and others have developed a curriculum in ethics and public health,1 an anticipation of the idea that population-based health could “lead the way” in the thawing of relations.2,3 Parallel academic exchanges have been a resounding success, leading to www.thelancet.com Vol 385 March 14, 2015
the preparation of joint manuscripts and participation in scientific and bioethics meetings. The relation has helped fledge a Cuban continuing educational programme on research ethics and ethics and public health. These collaborations are difficult because of current policies related to travel, communication, and currency restrictions. Fortunately, recent bilateral efforts, including high-level meetings in Havana in January, have engendered hope for expanded collaboration. Surely such collaboration, especially in public health and ethics, should be uncontroversial. Elimination of the US embargo, a sad policy failure that has advanced no legitimate US interest, but has magnified the suffering of the Cuban people, was endorsed by US President Barack Obama in his recent “State of the Union” speech.4 President Obama earlier issued an executive order to loosen some restrictions.5 This is a historic change, and, if our inchoate collaboration is any indicator, it signals future benefits for the American and Cuban people. We declare no competing interests.
Roberto Cañete, *Kenneth W Goodman [email protected] University of Medical Sciences and Provincial Centre of Hygiene, Epidemiology, and Microbiology, Matanzas City, Cuba (RC); and University of Miami Bioethics Program, Miami, FL 33101, USA (KWG) 1
2 3 4
5
Cañete R, Prior A, Brito K, Guilhem D, Novaes MR, Goodman KW. Development of an institutional curriculum in ethics and public health. Acta Bioeth 2013; 19: 251–57. Robbins A. Cuba-US relations: will public health lead the way? Lancet 2015; 385: e3. The Lancet. Cuba: health lessons not under embargo. Lancet 2015; 385: 2. The White House, Office of the Press Secretary. Remarks of President Barack Obama—As Prepared for Delivery State of the Union Address. January 20, 2015. http://www.whitehouse.gov/the-pressoffice/2015/01/20/remarks-president-barackobama-prepared-delivery-state-unionaddress (accessed Feb 17, 2015). The White House, Office of the Press Secretary. Statement by the President on Cuba Policy Changes. December 17, 2014. http://www.whitehouse.gov/the-pressoffice/2014/12/17/statement-presidentcuba-policy-changes. (accessed Feb 17, 2015).
West African Ebola crisis and orphans Every health crisis creates orphans, but Ebola causes disproportionate mortality among working-age adults, who are also the most likely to have young children. Across Guinea, Liberia, and Sierra Leone, individuals aged between 15 and 44 years make up 2·85 times as many of the Ebola patients as individuals under 15 years of age.1 Parent mortality has the potential to multiply the effects of Ebola by leading to poorer health and education outcomes in future generations.2 How many orphans is the Ebola epidemic creating? We infer the number of orphans using data on the gender and age distribution of cases and mortality from Ebola, the number of living children for adults, and data from previous epidemics on the probability of infection for spouses and children of Ebola patients (see appendix for more details).3 As of Feb 11, 2015, we estimate the children younger than 15 years orphaned by Ebola exceed 9600 (2100 in Guinea, 4200 in Liberia, and 3300 in Sierra Leone). Of 400 000
Published Online February 23, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60179-9
See Online for appendix
Total orphans (pre-Ebola) Ebola orphans
377 400
350 000 300 000 250 000
218 200
200 000 150 000 106 400
100 000 50 000 0
2100 Guinea
4200 Liberia
3300 Sierra Leone
Figure: Orphans in Guinea, Liberia, and Sierra Leone Numbers are rounded to the nearest hundred. Estimates of the total numbers of orphans before the Ebola outbreak are from the most recent demographic and health surveys in each country (see appendix). Estimates of the number of orphans attributed to Ebola were calculated using data from WHO as explained in reference 3 and summarised in the appendix.
945
For the InterAcademy Medical Panel statement see http:// www.iamp-online.org/ statements For more on Black Spring see http://en.wikipedia.org/wiki/ Black_Spring_%28Cuba%29
See Comment Lancet 2013; 382: 192
944
These numbers, concerning as they are, also hide another important factor. A disproportionate number of people struggle with the effects of hearing loss in low-income and middle-income countries. In wealthy countries, people generally have access to specialist medical care and can afford costly devices such as hearing aids and cochlear implants. In most developing countries, access to even the simplest of routine checks or hearing aid devices is scarce. Despite the fact that many of the causes of hearing loss can be identified and remedied, millions of people with hearing loss still live less than fulfilling lives, with associated detrimental effects on their families and wider society. For this reason, on March 3—International Ear Care Day—the InterAcademy Medical Panel (IAMP) releases its latest statement: A Call for Action to Strengthen Healthcare for Hearing Loss. IAMP represents 73 academies of medicine and medical branches of science academies worldwide, and among its objectives is provision of evidence-based advice to governments for health and science policy. The IAMP statement calls on governments and health-care providers: to implement improvements to health-care provision for hearing loss, such as universal hearing screening in birthing centres and improved affordability and accessibility of cochlear implantation; to implement policies to ensure that public health measures account for the causes of hearing loss; to address hearing loss in both children and adults while the differences between these groups are also acknowledged; to address broader societal needs, such as provision of educational programmes for children with hearing loss, their relatives, and communities; and to establish research and innovation programmes targeted at hearing loss priorities, including development of novel screening and diagnostic techniques to improve early identification of hearing loss in children and development of
affordable high-quality hearing aids and low-cost batteries. Despite being a common cause of functional and cognitive problems— and a major global health challenge— hearing loss is often preventable and avoidable. The time has come to rally around the key areas highlighted in the IAMP statement in a global, concerted, and sustained effort to improve the lives of all people with hearing loss. We declare no competing interests.
Lai Meng Looi, Detlev Ganten, *Peter F McGrath, Manfred Gross, George E Griffin [email protected] Academy of Sciences Malaysia, Kuala Lumpur, Malaysia (LML); German National Academy of Sciences Leopoldina, Berlin, Germany (DG); InterAcademy Medical Panel, Trieste 334151, Italy (PFMcG); Deparment of Audiology and Phoniatrics, Charité—Universitätsmedizin, Berlin, Germany (MG); and Deparments of Infectious Diseases and Medicine, St George’s, University of London, London, UK (GEG) 1
2
3
4
WHO. Millions of people in the world have hearing loss that can be treated or prevented. Geneva: World Health Organization, 2013. Lin FR, Thorpe R, Gordon-Salant S, Ferrucci L. Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci 2011; 66: 582–90. Gallacher J, Ilubaera V, Ben-Shlomo Y, et al. Auditory threshold, phonologic demand, and incident dementia. Neurology 2012; 79: 1583–90. Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol 2011; 68: 214–20.
Health in Cuba: the other side of the story In the past years, The Lancet has published Editorials and Comments in support of the public health situation in Cuba, without taking into consideration the country’s political situation. The Editors did this again in their recent Editorial (Jan 3, p 2),1 in which they support the re-establishment of diplomatic ties between Cuba and the USA on the matter of public health. However, Cubans live under a totalitarian regime that has silenced dissent, imprisoned,
and killed opposition leaders. 2 Persecution of dissidents continues today, as exemplified by the recent arrest of artist Tania Bruguera. In the public health arena we cannot forget the human-rights violations of patients with HIV/AIDS in the late 1980s and early 1990s, when HIV/AIDS tests were mandatory in Cuba, and people who tested positive were incarcerated in sanatoriums described by Jonathan Mann as “pretty prisons”.3 As stated in the Lancet Editorial,1 universal access to health care and education is a great accomplishment and a source of pride for the Cuban population. However, that same pride is eroded by a government that punishes the creativity of the Cuban population and limits the exercise of civil liberties. In 2003, during what is called Black Spring two economists were condemned to prison while documenting that public health and education in Cuba were already among the best in Latin America before the Revolution. In 1958, the infant mortality rate was 33 per 1000 livebirths, far lower than that of Argentina (61), Costa Rica (89) and Mexico (80).4 The Cuban Government sends doctors and nurses to work in Venezuela and Brazil for meagre salaries and retains most of their income.5 To use public health as a leading topic of the re-establishment of diplomatic relations between the USA and Cuba is a good idea, as your Editorial 1 and Anthony Robbins’ letter6 to The Lancet suggest. But there is another major opportunity: the positive effect of democracy on public health has been well documented. If the Cuban Government is so concerned about the health of its population, it could seriously consider a transition to democracy as part of the conditions for a new relation with the USA, not only for the sake of liberty, but also for the sake of the health of the Cuban population. I declare no competing interests.
www.thelancet.com Vol 385 March 14, 2015
Correspondence
Octavio Gómez-Dantés [email protected] National Institute of Public Health, Health Systems, 6210 Cuernavaca, Morelos, Mexico 1 2
3
4
5 6
The Lancet. Cuba: health lessons not under embargo. Lancet 2015; 385: 2. Human Rights Watch. Cuba´s repressive machinery. Human rights forty years after the revolution. http://www.hrw.org/reports/1999/ cuba (accessed Feb 12, 2015). McNeil DG. Cuba´s fortress against a viral foe. New York Times (New York), May 7, 2012. http:// www.nytimes.com/2012/05/08/health/cubasaids-sanitariums-fortresses-against-a-viral-foe. html (accessed Feb 12, 2015). Sixto FE. An evaluation of four decades of Cuban healthcare. http://www.ascecuba.org/c/wpcontent/uploads/2014/09/v12-sixto.pdf (accessed Feb 12, 2015). Devi S. Cuba’s economic reforms prompt debate about health care. Lancet 2014; 383: 294–95. Robbins A. Cuba–US relations: will public health lead the way? Lancet 2015; 385: e3.
Cuba–US collaboration and the role of bioethics For more than a half century, official relations between Cuba and the USA have been tense, fraught, and shaped by a mistrust which has not served the interests of ordinary Cubans or Americans. Despite official policies, some of those ordinary citizens— scholars, scientists, artists, and others—have forged ties based on mutual goals and objectives. One good example consists in apolitical efforts by the two countries’ bioethics communities, elements of which have hosted conferences, scholarly visits, and curriculum development projects. Topics have ranged from brain death to public health. For instance, the University of Miami Bioethics Program, the Research Ethics Committee of the Centre of Hygiene, Epidemiology and Microbiology in Matanzas City, and others have developed a curriculum in ethics and public health,1 an anticipation of the idea that population-based health could “lead the way” in the thawing of relations.2,3 Parallel academic exchanges have been a resounding success, leading to www.thelancet.com Vol 385 March 14, 2015
the preparation of joint manuscripts and participation in scientific and bioethics meetings. The relation has helped fledge a Cuban continuing educational programme on research ethics and ethics and public health. These collaborations are difficult because of current policies related to travel, communication, and currency restrictions. Fortunately, recent bilateral efforts, including high-level meetings in Havana in January, have engendered hope for expanded collaboration. Surely such collaboration, especially in public health and ethics, should be uncontroversial. Elimination of the US embargo, a sad policy failure that has advanced no legitimate US interest, but has magnified the suffering of the Cuban people, was endorsed by US President Barack Obama in his recent “State of the Union” speech.4 President Obama earlier issued an executive order to loosen some restrictions.5 This is a historic change, and, if our inchoate collaboration is any indicator, it signals future benefits for the American and Cuban people. We declare no competing interests.
Roberto Cañete, *Kenneth W Goodman [email protected] University of Medical Sciences and Provincial Centre of Hygiene, Epidemiology, and Microbiology, Matanzas City, Cuba (RC); and University of Miami Bioethics Program, Miami, FL 33101, USA (KWG) 1
2 3 4
5
Cañete R, Prior A, Brito K, Guilhem D, Novaes MR, Goodman KW. Development of an institutional curriculum in ethics and public health. Acta Bioeth 2013; 19: 251–57. Robbins A. Cuba-US relations: will public health lead the way? Lancet 2015; 385: e3. The Lancet. Cuba: health lessons not under embargo. Lancet 2015; 385: 2. The White House, Office of the Press Secretary. Remarks of President Barack Obama—As Prepared for Delivery State of the Union Address. January 20, 2015. http://www.whitehouse.gov/the-pressoffice/2015/01/20/remarks-president-barackobama-prepared-delivery-state-unionaddress (accessed Feb 17, 2015). The White House, Office of the Press Secretary. Statement by the President on Cuba Policy Changes. December 17, 2014. http://www.whitehouse.gov/the-pressoffice/2014/12/17/statement-presidentcuba-policy-changes. (accessed Feb 17, 2015).
West African Ebola crisis and orphans Every health crisis creates orphans, but Ebola causes disproportionate mortality among working-age adults, who are also the most likely to have young children. Across Guinea, Liberia, and Sierra Leone, individuals aged between 15 and 44 years make up 2·85 times as many of the Ebola patients as individuals under 15 years of age.1 Parent mortality has the potential to multiply the effects of Ebola by leading to poorer health and education outcomes in future generations.2 How many orphans is the Ebola epidemic creating? We infer the number of orphans using data on the gender and age distribution of cases and mortality from Ebola, the number of living children for adults, and data from previous epidemics on the probability of infection for spouses and children of Ebola patients (see appendix for more details).3 As of Feb 11, 2015, we estimate the children younger than 15 years orphaned by Ebola exceed 9600 (2100 in Guinea, 4200 in Liberia, and 3300 in Sierra Leone). Of 400 000
Published Online February 23, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60179-9
See Online for appendix
Total orphans (pre-Ebola) Ebola orphans
377 400
350 000 300 000 250 000
218 200
200 000 150 000 106 400
100 000 50 000 0
2100 Guinea
4200 Liberia
3300 Sierra Leone
Figure: Orphans in Guinea, Liberia, and Sierra Leone Numbers are rounded to the nearest hundred. Estimates of the total numbers of orphans before the Ebola outbreak are from the most recent demographic and health surveys in each country (see appendix). Estimates of the number of orphans attributed to Ebola were calculated using data from WHO as explained in reference 3 and summarised in the appendix.
945