SPOTLIGHT

Well Babies: Cuba's National Program

By Michele Frank, MD

Cubans in Cuba and the Diaspora are in love with children. You just need to see a street-wise teenager strutting his stuff, only to melt at the sight of a toddler. In Cuba itself, this cultural context of strong and extended family bonds is bolstered by programs prioritizing infants, young people and women in their reproductive years, and a community commitment to children that is reinforced by policy and effective popular advocacy.

The monitoring and improvement of conditions for healthy families and children is indeed a job for society at large. Educational levels of mothers and fathers, environmental concerns beginning in the home, safety for children at home and in their communities, schooling and opportunities-all these factors and more play their part in determining the quality of childhood and the passage to maturity.

In Cuba's case, for nearly five decades, considerable expertise and available resources have been devoted to shaping a national network for the promotion of maternal-child health, with special emphasis on the first year of life when children are most vulnerable. One key element has been integration of efforts and cooperation among health, education and justice ministries; local government; service agencies and community-based organizations such as the Federation of Cuban Women, Neighborhood Transformation Workshops and others.

Nevertheless, the Ministry of Public Health's share of this responsibility is a hefty one, summarized in its National Program for Maternal-Child Health (PAMI), which is considered one of the most important within the Cuban health system. PAMI has a key role and influence as an oversight body at the national, provincial and municipal levels. And it is fair to say that beyond the political will this framework represents, infants, children and family well-being are a driving force behind the personal commitment of Cuban health professionals. The family doctor-and-nurse teams-located literally in every Cuban neighborhood and rural settlement-are the first link in a chain that involves ob-gyn's, neonatologists, pediatricians and other specialists.

The results taken together affirm that protection of women's and children's health is possible, even in relatively resource-scarce settings of developing countries-an encouraging message as the world struggles to cope with the crisis of childhood confronting humankind today.

The International Picture of Child Health:
An Urgent Call

The World Health Organization's (WHO) World Health Report 2005 - Make Every Mother and Child Count , is a compelling call detailing the current situation: ".this year almost 11 million children under five years of age will die from causes that are largely preventable. Among them are 4 million babies who will not survive the first month of life." The report continues, stating that "reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right to access to health care from pregnancy through childbirth, the neonatal period and childhood."

The Millennium Development Goals report reveals what can only be described as the shameful inequity of children's chances around the globe: "More than 10 million children die each year in the developing world, the vast majority from causes preventable through a combination of good care, nutrition, and medical treatment. In developing countries one child in 10 dies before its fifth birthday, compared with 1 in 143 in high-income countries.".

Recently, a special series in The Lancet added the important medical journal's voice to the clamor for solutions to the crisis: "Eight million children are still born or die each year within the first month of life. This figure never makes news. The issue of child survival is a moral as well as a health barometer of our times. The aim of the present Lancet series (Neonatal Survival) is to erase the excuse of ignorance for public and political inaction once and for all.

"This series is the product of a partnership between scientists, health workers, and journal editors. Together we can make a difference to the lives of those who have no voice. We believe that this is the most important public health campaign we have taken part in for a generation."

Cuba's Contribution

In Cuba, there has been a relatively rapid transformation in child health indicators - from a ranking typical of a developing country to one on par with the industrialized countries. (For comparative data, see MEDICC Review , Vol. VII, No. 1, 2005, Cuba Hits Record Low Infant Mortality) Losing babies is still very much a part of Cubans' collective memory; yet their health profile today is astonishingly positive. So how do they do it?

"Everybody cares about this.it's an ongoing process, a work in progress," Dr. Elsa Gutierrez told MEDICC Review . Director of Havana's Adolescent Clinic and Professor Emeritus of Medicine, Pediatrics and Child Psychiatry at Havana's Higher Institute of Medical Sciences, Dr. Gutierrez is a passionate advocate for children and families.

"In the first place," she says, "it takes respect, respect for children." As one of the first countries to sign on to the UN Convention on the Rights of the Child, Cuba works with UNICEF in public information materials and campaigns about the content and spirit of the Convention.

"We take this idea of the rights of children very seriously," says Dr. Gutierrez - it is very important.

It not only is protective of children but it also is educational, it teaches them about what they should stand for, it empowers them. This creates hope - we need more hope for our young people in this world. They are inheriting quite a mess; we should support them in every way we can."

The First Year of Life

Like adolescent health, one of Dr. Gutierrez's specialties, pre-natal care is also constantly evolving. As a result of the implementation of the family doctor-and-nurse program in the late 1980s, the pyramid of care rests on this duo in each neighborhood. The essential principle of the team is that they are their community's "guardians of health" and, as such, concentrate many of their efforts on prevention.

In the case of mothers-to-be, family doctors are expected to carry out a thorough intake exam by no later than the 9th week of pregnancy. A healthy, problem-free pregnancy involves at least 12 pre-natal visits and a battery of regular lab tests and screenings. Ultrasound is part of standard pre-natal care, available now at local polyclinics. Paid time off from work for pre-natal visits is the law, as is an extensive maternity leave.

Cuban poster promoting breast-feeding.

High risk pregnancies get special and individualized attention, and family doctors rely on a wide range of services and facilities as back-up for their recommendations to patients for ensuring a healthy pregnancy and birth. This can include special tests, community-based maternity homes with both day programs and overnight facilities, supplementary nutrition programs, and inter-consultation with other specialists (pediatric cardiologists, obstetricians, pediatricians, etc.).

Education of mothers and fathers is receiving more attention in recent years. For example, in informal sessions, physicians regularly inform pregnant women of the benefits of exclusive breast-feeding for at least the first 4 months of life; and they involve both parents as much as possible from the start, including preparing the couple for any anticipated health problems the newborn might present. Encouraging participation by both mother and father extends to the legal option for paternity leave (see Cuba's Maternity Leave Extended to Fathers , this issue), and for authorized absence from work by either parent in the case of a sick or hospitalized child.

In-hospital births surpass 99%, and the majority of Cuba's maternity hospitals have been awarded the UNICEF distinction of "Mother and Baby Friendly Hospital," based on a series of parameters including the percentage of women who leave the hospital exclusively breast-feeding their newborns.

UNICEF has continually praised Cuba's work in this field, and its dedication in general to children's health-choosing to pilot several programs on the island. "It's quite easy to work on health projects in Cuba with the Ministry of Public Health," says Dr. Odalys Rodriguez of UNICEF-Cuba. "We get full cooperation and the appreciation is palpable."

Family doctors frequently visit their patients-mothers and newborns-in the hospital, and they do the first full intake exam within 72 hours of the baby's arrival home. This first well-baby appointment is a house call; and from then on, mothers will take their infants to the family physician for regular check-ups, and to pediatricians who rotate through family doctor offices for team consultations.

Beginning in their first year, Cuban children are immunized against 13 childhood diseases (see MEDICC Review Vol. VI No. 1, 2004, Cuba's National Immunization Program). In 2004, the program received the Pan American Health Organization's highest rating, as a result of an extensive evaluation visit by the PAHO/WHO Immunization Unit. "The quality and organizational consistency and systematic application of the Cuban immunization program is impressive and significant," reported Dr. Jon Him Andrus, head of the Unit and the evaluation team. He strongly encouraged Cuban health authorities to do more to share the experience with other countries.

The comprehensive care offered to mothers and newborns under the Maternal-Child Health Program-relying on accessible and free services across the country-has made a strong impact on health equity for children in the country, reflected in the following chart comparing infant mortality rates in all Cuban provinces and territories.

Attention to Cuban babies in their first year of life, as Dr. Gutierrez says, is indeed a "work in progress". As the research institutes develop and produce new vaccines, Cuban children benefit. (See Camaraza, M et al, Induced immunogenicity by means of the VA-MENGOC-BC ® anti-meningococcal vaccine against the ATCC C11 N. Meningitides strain in adolescents 12 years after vaccination . Rev Cub Med Trop 2004 56(1):26-30).

New and specialized screenings, such as early detection of hearing loss in infants developed by the Cuban Neuroscience Center, has made it possible to implement early intervention in the hearing impaired starting as early as 3 months of age. Likewise, the national children's heart network is designed to provide specialized coverage for all Cuban babies in need of this level of attention (see MEDICC Review , Vol. VII, No. 1, 2005 Treating Children with Congenital Heart Problems: It Takes a Network ).

Much of the attention in the PAMI program now focuses on tackling the leading causes of infant death in Cuba, which at this point are quite similar to those in developed countries.

Still, Dr. Gutierrez concedes there is much work to be done to improve things. This is one of the main goals of PAMI - to identify problems, areas that need improvement, and then address them.

"We still have teen pregnancy, it's going down, but it is still an issue - perhaps not as big a problem as in other countries. But for us it is a problem until it is resolved.

"There are many ways that young people can access information on family planning, HIV-AIDS, drugs, and other health issues, but we can, should and will do more."