Enrique Vega, MD
Director of Cuba's National Program of Attention to Older
Persons
Ministry of Public Health
Deputy Director, Ibero-American Center on Aging
Chief of Geriatrics Services, Calixto García Hospital, Havana
R. VEGA HAD PLANNED
to enter neurology, until one of his medical professors convinced him
to take up the challenge of geriatrics. "And challenge it was from
the outset," he comments. "I spent six months in Switzerland, where
the most important thing I learned was that in Cuba, we would have to
formulate a wholly different and homegrown approach, if we were to address
the needs of older persons in a developing country such as ours."
MR
interviewed Dr. Vega at the Ibero-American Center on Aging, headquartered
in the Borges Pavilion of Havana's 800-bed Calixto García Clinical/Surgical
Hospital.
MR:
We all know intuitively what aging is, but as a specialist, what do you find
is the most useful definition of aging?
EV:
I
would describe it as the process of diminishing reserves. As people
age, on the surface they lose only a few of their capabilities. But
more importantly, they lose their reserves, and this is most evident when
they are under stress. For example, an older patient and I might take
off running to catch a bus at the same pace, but after a few yards the difference
in our reserves would become apparent, as the strain on his or her system
would reveal diminished reserves.
These diminished reserves are not only
biological, however. They are also psychological and social.
And the three are intimately related. That's why in an older person,
for example, you might find the first symptom of pneumonia to be the sudden
appearance of crying spells. This patient's psychological reserves
were the "shallowest", and so that's where the first symptom appeared.
Or take an older person who twists an ankle, not a complicated condition
biologically-speaking. But if that person lives alone, without social
reserves, their situation could indeed become quite complicated both biologically
and psychologically.
Fragility in these older people is not only
defined in a biological sense, either. And this is key when we seek to identify
the fragile members of the over-60 community, in order to prioritize their
attention by the health system, and to catch the crises before they happen.
MR:
Before we get into the Cuban public health system's approach towards aging,
tell me about the particular challenges Cuba faces in this field. How
is aging in Cuba the same or different from the picture in other countries?
EV:
The
world is seeing a whole new phenomenon in the 21st Century:
for the first time, we are seeing poor countries with significant populations
over 60. For example, while the percentage of inhabitants over 60 in
Brazil or Mexico may still be relatively small, they now translate into millions
of people.
Cuba is one of these poor countries with
a significant over-60 population-both proportionately and in absolute terms.
In fact, we are the "oldest" population in Latin America: 13.6% of
Cubans or 1.4 million people are today over 60. The main challenge
before all our countries is how to guarantee a satisfactory quality of life
for this growing population, people who depend heavily on medical, social
security and other services within our severe economic constraints.
When people age well, they do not present
a "problem": on the contrary, they are a treasure. But when
they are ill or totally dependent on society's care for prolonged periods
of time, this poses an immediate strain on resources. For example,
in Cuba only 0.7% of older people live in homes for the elderly, and if
we don't have more space for them, it's because we simply don't have the
resources to provide the beds.
Which brings me to a key difference between
Cuba and many other societies: by tradition, the overwhelming number
of older people (90%) live within the family unit. This means that
the family and the community are central to their lives, and must be central
to public health and other support systems, participatory actions and so
forth.
Who are the older people in Cuba?
They tend to be women more than men, a process which some have called the
"feminization" of old age. 14.1% of women in Cuba are over the age
of 60. Older people are also concentrated in the urban centers of
the country, which is not surprising given that Cuba's population is majority
urban. In Havana City, for example, three municipalities have over-60
populations of 20% or more (Central Havana, 10 de Octubre, Plaza de la Revolución).
They have the aging patterns of Sweden, but the economy of a poor developing
country.
MR:
How are Cuban planners going about meeting this challenge of a rapidly aging
population in a struggling economy?
EV:
Last year (1999), we held a national intersectorial meeting, to look at where
we are and where we have to go in each sector, and to begin to coordinate
efforts. Because the first thing you must realize is that if you are
going to make Cuba's a more "aging-friendly society", then that means you
have to involve virtually every ministry and agency in the country. We realized
that, since the capabilities of older persons to adapt to society are progressively
reduced, what we must try to do is adapt society to them.
For example, we began to look at transportation:
we don't have "kneeling buses" or anything of the kind. What can we
do to make public transportation less of an ordeal for elderly people?
The streets are full of potholes, and older
people prone to accidents. What can we do to prioritize the potholes?
Older
people's homes are often a source of accidents as well. Not only are
they in disrepair, but when new housing is assigned, sometimes the apartment
they are given will be on the fourth instead of the first floor. Age
isn't yet taken into consideration here.
Retirement is voluntary in Cuba, among women
from age 55 and men from age 60. But it's an all-or-nothing system:
you're either in or out of the workforce. We are now looking at ways
to build in more flexibility, to let people work part-time or at home, which
helps older people and also boosts the workforce.
The community support we can give to families
with older members is still insufficient: this is why the Senior Citizens'
Centers are so important to extend across the country (see Spotlight....).
Then, there is the delicate task of convincing families to look at their
older members differently. This is very difficult. You have
to remember that the 20th Century was one of tremendous changes-people
alive today may have aged 70 years, but society "aged" or developed 400-500
years in that same period, at an accelerated rate. If someone is in
their 90s, they knew the age of horse-drawn carriages: how can they
conceive of the Internet? So the tendency is for younger members of
the family (and the community) to under-value those older people who haven't
mastered the new technologies. This is part of the generational conflict
that gets played out in Cuba. And if you add a crowded housing situation,
the frictions can become worse.
Now, in reality, older people psychologically
lose and gain capabilities at the same time: they may lose their ability
to do many things at one time, but gain in powers of concentration, or in
the patience it takes to teach a grandchild. And in Cuba, one of the
positive things is that older people are the ones who have been through
many "battles": they are tough, and they are used to speaking for
themselves. That is an advantage.
MR:
At the family
and community level, how does the public health system provide
support now for older persons in Cuba?
EV:
The
main way is through the family doctor-and-nurse team and the EMAG (Multi-disciplinary
Gerontology Team) at the level of the community polyclinic. As you know,
the family doctors and nurses are situated in neighborhoods throughout Cuba,
and now attend to 98% of the population: this brings health-care services
very close to people in need, very close to those who tend towards chronic
conditions, such as the elderly. It gives them a sense of security,
and allows us to take a more long-range, preventive approach and to counsel
seniors on life-style and other changes that can give them fuller lives.
The Gerontology Teams, in turn, are made
up of a family doctor, psychologist, nurse and social worker. They
rely on the family doctor-and-nurse annual survey of their patients, to
bring to their attention the approximately 10% who may be "fragile" older
patients. The Gerontology Team confirms this assessment, and then
recommends special attention and followup on an individual basis.
These Teams now exist in every Health Area (community) in the country.
We are now in the process of offering a
special post-graduate course to each of these Teams across Cuba: 40%
have already taken the course, which makes them more aware and more efficient
in carrying out their work. Their final "thesis" for the course is
to fully implement the Comprehensive Program for Attention to the Elderly
(see Spotlight...) in their particular patient population.
Thus far, this approach is giving us excellent results. There is much
more
to do.....
