The elderly in Cuba:
Main demographic trends, morbidity and mortality

Leocadio Martínez Almanza, M.D., Jesús Menéndez Jiménez, M.D., Elsy Cáceres Manso, M.Sc., Moisés Baly Baly,  M.Sc., Enrique Vega García, M.D. , Osvaldo Prieto Ramos, M.D.

ABSTRACT:  Explores and describes the most relevant aspects of aging and old age in Cuba.  The trends herein reviewed pose a challenge for Cuba and the world, magnified by the structural and resource limitations in many countries.  To this must be added the imperative need to increase awareness of the situation and identify the objective tendencies it represents.  Morbidity and mortality rates in Cuba, in the context of general population aging, serve as a starting point for research to guide the resource mobilization and the development of national strategies.

n the time of the Roman Empire, people were considered old by the age of 20.  Half the population died at the age of 27 from infections diseases.  In the Middle Ages, people were considered old at 25; at the age of 30, in the 18^th century; and at  40, in the 1900s.  Today, people are considered "young" at 50¹ (United Nations.  The Dangers of Geriatric Impact Will be Seen Within a Decade.  Daily Information Services for Health Professionals, 1997, Nov. 3).

The goal of our current study is to gather updated quantitative and qualitative data on demographic and social aspects of population aging, as well as on the processes of health and disease in this age group in Cuba and worldwide.  Our information sources include: the National Statistics Division, Cuban Ministry of Public Health and from the Ministry's Division ford Social Assistance and Aging; the Pan American Health Organization (PAHO); Ibero-American Centeron Aging (CITED); Cuba's National Statistics Office and National Medical Library-including the MEDLINE and LILAC databases. 

(MR Editor's Note:  An introductory section on "World Population Aging" follows in the original manuscript, which we have not included in this English excerpt.)

Population Aging in Cuba

Table 1.
World Demographic Indicators, Including Cuba and Selected Regions.  1995-2000

Indicator	Cuba1	Latin America and the Caribbean	Developing Countries	Developed Countries	World
Mortality Rate*	7.20	6.50	8.50	10.20	8.80
Birth Rate*	12.70	23.90	26.50	12.20	23.70
Fertility Rate (children/woman)	1.44	2.83	3.28	1.77	2.97
Rate of Population Growth*	3.60	16.70	17.80	3.20	14.90
Percent of People over 602	12.30	7.60	8.50	21.20	10.70

¹1995        ² 1996      *Rate per 1,000 inhabitants

Source: United Nations.  World Population Prospects .  (1994 Revision).  Cuban National Statistics Office, 1997.  Statistical Yearbook, 1996.

The  Cuban population has experienced significant changes over the 20^th  Century, mainly during the last 35 years (Cuban National Statistics Office: Statistical Yearbook, 1996 and Population Prospects for the Cuban Population, 1995-2015.  Havana, 1997).  By 1960, Cuba had 7,000,000 inhabitants; by January,1996, that number had reached 11,000,000.  In the year 2000, the Cuban population is expected to be over 11,100,000, and by 2020 to reach 11,700,000.

The population dynamics in Cuba over the last few decades reveal evident population aging (Cuban National Statistics Office:  Population Database. 1996).  Furthermore, population projections show that by the year 2025 Cuba will be the "oldest" country in the region.

Data reveal that on December 31, 1997, 13.1% of the Cuban population (1,400,000 inhabitants) was people over 60 (Table 2), with women in the majority in this age group (51.4%).  According to population projections, by the year 2025, women will comprise 55.0% of the over-60 group in Cuba, which by that time will account for almost 24% of the population.  Worldwide, there is a tendency for the numbers of men over 60 to decrease, a phenomenon associated with the comparatively greater mortality rates for men in this age group.(Cuban National Statistics Office: Statistical Yearbook, 1996.  Havana, 1997).

Table 2.  Population Distribution by Age (%). 

Cuba for Selected years
Years	0-14	15-19	over 60	Years	0-14	15-19	over 60
19071	36.6	58.2	4.6	19811	30.3	58.8	10.9
10191	42.3	52.9	4.8	19912	22.4	65.5	12.1
19311	37.4	57.5	5.1	19952	22.2	65.1	12.7
19431	35.5	58.9	5.6	19962	22.2	64.8	13.0
19531	36.2	56.9	6.9	19972	22.0	64.9	13.1
19701	36.9	54.0	9.1

¹Housing and Population Census, ²Statistics Information System

Source: Cuban National Statistics Office, Development Studies Center:  Estudios y datos sobre población, 1998.

By the year 2010, the Cuban population over 60 is expected to grow to 16.5% of the general population (2,000,000 inhabitants), and to 18.4% by the year 2015.  Moreover the number of people over 60  for the year 2015 is expected to outnumber, both in relative and absolute terms, the population between 0 and 14 years of age (less than 17%).  The mean age for that year is estimated at nearly 40 years-31 today (Cuban National Statistics Office, Development Studies Center.  La población cubana en el contexto mundial.  Havana, Cuba, 1998).

Life expectancy has evolved in Cuba in a very particular way, reflecting the economic and social situations of the times.  In 1900, it was 33.2 years; in 1930, 41.5 years-a growth of 8.3 years--; and in 1953, it reached 58.8 years.  This pattern became more evident in subsequent decades, and by 1971, life expectancy stood at 70.0 years; in 1987, at 74.4 years.¹⁰

The growth of the over-60 population in Cuba has not been homogeneous.  The proportion of older people in the western and central provinces is higher than in the eastern provinces, due mostly to differences in fertility rates, among other factors. Villa Clara and Ciudad de La Habana Provinces are the "oldest" in Cuba, with over 15% of their population over 60 years old.

Life expectancy for people who have reached 60 has increased considerably in Cuba.  In 1950, they could expect to live an additional 15.5 years, and less than 40 years later, this figure reached 20.5 years.¹¹

These levels of life expectancy for elderly people are comparable to the highest in the world:  life expectancy for men who have reached 60 is 19.5 years and for women 21.1 years.
(Table 3) (Cuban National Statistics Office: Statistical Yearbook 1996.  Havana, 1997).

Table 3.  Life Expectancy in Cuba by Sex and Selected Age Groups, 1989 (in years)

Age	Both Sexes	Male	Female
60	20.65	19.60	21.81
65	16.95	16.00	17.93
70	13.45	12.70	14.28
75	10.37	9.77	11.03
80	7.89	7.40	8.43
85	5.68	5.36	6.05

Source: Rojas Ochoa F.  Estado de Salud de la Tercera Edad, 1993   

Increased life expectancy among older people in Cuba has brought an increase in the number of so-called "older old people" (Table 3), with the special socioeconomic and medical needs this implies. These figures are similar to those of some developed countries.  In Cuba today, life expectancy for people who are 80 years old is 7.6 years.

In a country with such a rate of population aging, important social and healthcare-related changes take place, especially regarding the rates of morbidity and mortality, disabilities and the use of healthcare services.^12,13

This increases the demand for further scientific knowledge, as well as for the identification of factors that contribute to preserve the health status of older people, aimed at improving their wellbeing.

Moreover, social security, labor resources and the structure of the economically active population (EAP) are other important dimensions of  population aging.  Furthermore, the median age of the Cuban EAP will increase to approximately 42 years by 2015-an important and complex fact.  The impact of population aging in Cuba will be more tangible in the spheres of social security and social assistance, for various reasons.  First, due to the universal coverage of these services as well as the government funds earmarked for the needs of the population, temporary benefits and retirement pensions (Cuban Institute of Hygiene, Epidemiology and Microbiology:  National Survey of Risk Factors and Preventive Actions for Non-communicable Diseases. 1995).  In this respect, toward the end of 1980s and the beginning of 1990s, the Cuban economy entered a period of crisis known as the "Special Period", mainly due to external factors related with the collapse of the European socialist bloc-Cuba's main trading partners.  The impact of this event on the Cuban economy has been significant, and living standards of the Cuban population-including the elderly--were seriously affected.

The worldwide increase in the number of people over 60 poses a problem for many countries.  Factors related to lifestyle and behavior, such as smoking, alcohol consumption, nutrition, physical exercise, education, etc., are of crucial importance not only because of their relation to disease,  but also to the natural processes of aging. All these influence the health status of the elderly.

Main Health Problems in People over 60 in Cuba

The 1995 National Survey of Risk Factors and Prevention for Non-communicable Diseases revealed interesting data on lifestyle and non-communicable diseases in Cubans over 60.  The study found that approximately 35.0% of older people smoke; and less than 1.0% were reported as alcoholics.  The survey showed that almost 69% of older people suffer from hypertension, including both the already diagnosed plus newly reported cases; 51% had a sedentary lifestyle; and among older people, there was a greater tendency towards overweight than towards underweight. (National Statistics Office: National Survey of People over 60 in Cuba, 1989).

Although most people over 60 are without major disabilities, a portion of them become more fragile with age, and require support, attention or institutionalization, many times for the rest of their lives.  Unlike younger people, the elderly suffer from comparatively more chronic diseases and make more use of health care and social services-mainly due to increased disabilities (20-30% of the population over 85 suffers some kind of disability). ¹⁴

The 1985 National Survey of People over 60 , sponsored by the Pan American Health Organization, showed that 69.6% of those Cubans surveyed suffered from at least one chronic illness, and 13.9% from sensory disorders.  Hearing tests on those with and without the assistance of hearing aids showed that most older people had good or fair hearing.  Their vision, including both those who used corrective lenses and those without, was good or fair in 80.9% of the cases. 

As Table 4 illustrates, hypertension is the most frequent non-communicable disease among older people, followed by diabetes mellitus and ischemic heart disease.  Several studies have been conducted in Cuba to evaluate morbidity in people over 60.  Various local studies reveal similar results as those conducted nationally.^15,16 (Chinique L: Prevalencia de enfermedades crónicas en un área de salud.   Residency thesis.  Havana, 1989; Muñiz P.:  Morbilidad por enfermedades crónicas en ancianos de un consultorio del médico de familia.  Residency thesis.  Havana, 1990).

Table 4.   Prevalence of Non-communicable Diseases

Age (years)	Diabetes Mellitus	Hypertension	Ischemic Heart Disease	Cerebrovascular Disease
60 - 64	86.17	264.0	70.01	13.34
over 65	73.42	201.3	77.71	16.07

Rate per 1,000 inhabitants over 60 years of age

Source:  Statistical Yearbook.   Cuban Ministry of Public Health, 1996.

Morbidity and mortality for selected communicable diseases (Table 5) shows an evident increase in the risk of contracting acute respiratory infections (20.4 per 10⁵ higher than in previous years) and dying from them primarily in the provinces of La Habana, Ciudad de La Habana, Matanzas and Villa Clara.  This risk is substantially less for tuberculosis and acute diarrheal diseases.  However,  Sancti Spíritus and Ciego de Ávila Provinces as well as the Isle of Youth Special Municipality, show a higher morbidity rate from tuberculosis than other provinces, while Pinar del Río, Villa Clara and Camagüey Provinces, among others, a the mortality rate from this disease.

Table 5.  Morbidity and Mortality for Selected Communicable Diseases, 1998.

Variable	Acute Respiratory Infections	Acute Diarrheal Diseases	Tuberculosis
Morbidity	308.71	64.71	23.5
Mortality	319.02	23.62	3.5

¹ Rate per 1,000 inhabitants over 60 years of age.  
² Rate per 100,000 inhabitants over 60 years of age.

Source: Cuban Statistics Office.  Cuban Ministry of Public Health, 1998.

Respiratory infections have serious implications for older people.  In Cuba, mortality rates among people over 60 who contracted respiratory infections were 228.9 in 1995 and 283.8 in 1996 (per 100,000 inhabitants) (Table 6 ). Mortality rates for influenza and pneumonia (Table 7) were 227.9 in 1995, and 282.2 in 1996 (per 100,000 inhabitants).  Mortality from tuberculosis was 4.6 per 100,000 inhabitants in 1996; and from acute diarrheal disorders ( Table 6) 25.0 for older people in 1989, 34.9 in 1995; 31.3 in 1996 and 23.6 in 1998 (all per 100,000 inhabitants).

Infectious diseases are no longer among the main causes of death for people over 60 in Cuba.¹⁷ (Puchkodd Lastres L.  Infecciones en pacientes de la tercera edad ingresados en el CITED.  Master's thesis.  Havana, 1995.)

Among the risk factors for pneumonia are smoking, alcoholism, and concomitant diseases.¹⁸ People over 60 have a higher risk of developing active tuberculosis, and moreover they are the main risk group for this disease.^19,20

Table 6.  Mortality in Cuba from Selected Causes in People over 60, 1989-1998
               (Rates per 10⁵)

Year	Acute Respiratory Infections	Acute Diarrheal Diseases (ADD)	Accidents	Suicide
1989	163.8	12.3	137.7	46.3
1990	210.8	18.8	149.4	50.2
1991	221.9	22.6	158.6	47.7
1992	236.5	25.6	180.4	54.4
1993	283.8	42.8	184.4	62.2
1994	291.4	42.6	179.0	58.2
1995	228.9	34.9	193.1	51.4
1996	283.8	31.2	197.2	47.1
1997	314.1	26.2	186.1	47.9
1998*	319.0	23.6	186.2	51.2

  * Preliminary Data

Source: Cuban Statistics Office. Cuban Ministry of Public Health.  January, 1999.

Morbidity and mortality rates increase with age, and among the elderly they are higher for men than women. The morbidity rate is also generally higher in cities than in rural areas.

Diarrhea is a common health problem in older people and can cause adverse consequences.  Dehydration and infections are among the factors that have proven to affect the morbidity and mortality rates for geriatric depression.²¹

Perhaps the most important risk factor for diarrhea among older people is living in a home for the elderly or any other institutional facility:  there is no doubt that these are the elderly with the highest incidence of diarrhea.  Outbreaks of diarrheal diseases are quite common in these institutions, which can result in significant mortality.²¹

Table 7.   Main Causes of Death in Cuba for People over 60 (1989, 1995-1998)

Cause	1989	1995	1996	1997	1998
Ischemic Heart Disease	1198.8	1122.5	1146.2	1073.5	1056.9
Malignant Tumors	773.3	774.6	798.6	778.3	798.4
Cerebrovascular Disease	476.3	477.3	415.6	458.7	461.3
Influenza and Pneumonia	235.6	227.9	282.2	312.0	283.5
Hip Fracture	84.3	103.4	151.6	123.7	124.5

Rate per 100,000 inhabitants over 60 years of age.

Source:  Statistical Yearbook. . Cuban Ministry of Public Health, 1996. 
                Cuban Statistics Office, Ministry of Public Health, 1998.

Overall, we observe a slight increase in mortality rates of persons over 60 (Table 8), including a discreet increase in 1998 (rate: 40.9 per 1,000) over 1997, representing a difference of 0.2 per 1,000 inhabitants), mainly because of higher mortality among the 60-74 age group, and primarily reflecting the situation in the provinces of La Habana, Cienfuegos and Villa Clara.  These rates decreased over 1997 in the eastern provinces from Ciego de Avila to Santiago de Cuba, except for Camagüey.  Of the total number of people who died in 1997, 74.8% were over 60, an increase of 7.8% over 1980 figures.

Analyzing selected causes of death among non-communicable chronic diseases, we find an increase for chronic obstructive pulmonary disease over the previous year-109.1 per 10⁵ in 1998, indicating a difference of 14.6 per 10^5.   The provinces with higher mortality were Pinar del Río, Villa Clara, Cienfuegos and Sancti Spíritus.  There was also an increase in the risk of death by cerebrovascular disease (Table 7 ), and a decrease in the case of diabetes (rate: 93.4 in 1998 vs. 109.2 per 10⁵in 1997) as well as ischemic heart disease.  However, the latter continues to be the main cause of death for Cuba's Cuban population and the world's. Ischemic heart disease is also the main cause of death for people over 60, the risk increasing with age.  Death from ischemic heart disease is more frequent among men than women. 

Cancer (Table 7) is the second cause of death in older people, this risk increasing with age until approximately 80 years old.  In people over 80, however, cancer causes a comparatively smaller number of deaths than in younger age groups.^7,8,22,23

Overall, the death rate by age for neoplasms has increased from 30 to 50% in men since 1950, and has declined 10% in women.⁸

In Cuba, the death rates in people over 60 for malignant tumors were 774.6 in 1995 and 798.6 in 1996 (per 10⁵ inhabitants).  Lung cancer was the most common form. (Statistics Office.  Cuban Ministry of Public Health.  Indicadores de salud en la población de la tercera edad, 1998;  Situación de salud en Cuba.  Indicadores básicos, 1996; Statistical Yearbook, 1996).

Other health problems are have an important incidence in this rate, such as hip fractures (Table 7), suicides and accidents ( Table 6).  These three health problems were responsible for an increase in 1998 mortality rates.

In Cuba, the mortality rate from accidents in people over 60 was to 193.1 in 1995; and 197.4, in 1996 (rate per 10⁵ inhabitants).

Home accidents affect mainly children and older people-the two most vulnerable groups in this respect.  In older people the most common accident is falls²⁴ followed by fire.  Elder²⁵ published an article offering his findings on accidental fires and deaths from burns among older people in Scotland (1980 to 1990).  He stated that of 1,096 people who died in fires during that period, 243 (23%) were people over 75 years of age.  He also pointed to poor use or disrepair of household electrical appliances as the main causes of these fires.

Table 8.   Mortality Rates in People over 60.  Cuba.  1993-1998.

Age	1989	1993	1995	1996	1997	1998*
60+	38.6	46.3	41.6	43.0	40.7	40.9
60-64	13.4	14.2	12.6	13.2	12.3	13.8
65-69	22.2	21.4	20.4	21.1	19.8	20.8
70-74	29.1	36.3	32.5	33.2	32.0	32.5
75+	81.1	91.7	90.2	94.7	90.9	84.3

Rate per 1,000 inhabitants 60 and over.
*Preliminary Data

Source: Cuban Statistics Office, Ministry of Public Health, 1998.

Falls are considered one of the most frequent causes of accidental deaths in older people.  Gutiérrez Robledo²⁶ writes that approximately 25% of older people who fall in their homes suffer serious injuries.

Two articles on the subject have been published recently in Cuba.  In 1996, Gómez conducted a study on the risk of falls in older people in the Los Sitios neighborhood of Havana, with consideration given to sociodemographic variables.  A year later, Rodríguez Rivas validated Gómez's outcomes, for which he used the Periodic Health Exam (Gómez A. Riesgos de caídas en ancianos en cuatro consultorios del Consejo Popular Los Sitios.  Residency thesis.  Havana, 1996.  Rodríguez R. Validación del riesgo de caídas en ancianos del Consejo Popular de Los Sitios.  Master's thesis.  Havana, 1997).

Fracture of the humerus, wrist, pelvis and hip are considered age-related fractures, which usually occur from the combined result of falls and osteoporosis.²⁷

The incidence of hip fracture varies markedly worldwide.  South Africa has reported 5.6; Spain, 27; Hong Kong 31.54; England 43; Switzerland 69.6; U.S., 80; Japan, 29.2 for men and 84.0 for women (rates per 100,000 inhabitants).²⁸

Some experts predict the number of hip fractures among older people will double or triple by the year 2050; others say it will only take another 20 years before this happens. ²⁸

The overall mortality rate within a year of suffering hip fracture ranges between 14 and 36%.  Most authors agree that the highest risk of death is within the first 4 or 6 months after the fracture.  After the first year, the mortality rates are comparable to those of older people who have not suffered fractures.²⁸

In Cuba (Table 7 ), the mortality rate among the elderly from hip fractures in 1989 was 84.3; and in 1998, 124.5 (per 10^{5 i}nhabitants). 

Suicide is considered an external intentional cause of death.  Legally, suicide is defined as an intentional act of self-destruction committed by a person aware of what he or she is doing and of the probable consequences of his or her act.²⁹ Mesa³⁰ states that there is a functioning axiom in the epidemiology of suicide:  risk increases with age.  The problem of suicide among older people is a complex one.  During the 20^th century, two interesting developments have occured.  First, the relationship between age and suicide attempts has changed.  From 1900 to 1920, suicide attempts were more prevalent among younger people (15-25 years old); in the 1930s, among people ages 25-40; and by 1950, among those ages 40-50-a tendency which has remained constant since then.  The second development relates to motivations for attempting suicide.  In the last 30 years, the most frequently alleged apparent motivation has been generalized ennui-quite different from the motivations in other eras:  infidelity, financial problems, disgraceful experiences, etc.³⁰

In Cuba (Table 6) the suicide rate for 1989 was 46.3, 47.9 in 1997, and 51.2 in 1998 for both sexes. Villa Clara, Ciego de Avila and Matanzas Provinces and the Isle of Youth Special Municipality were particularly responsible for the 1998 increase over 1997.

Multiple factors intervene in the degenerative process associated with chronic diseases related to aging. Most of these diseases have already appeared by the time people reach the age of 60.  Chronic diseases are one of the main causes of morbidity and mortality in Cuba-a country with significantly positive epidemiological achievements.

In many cases, it is more important to know the older person's competence at daily activities-even when this is limited--than to know morbidity from chronic diseases or even the attention required to these conditions.

Table 9 exhibits outcomes from the National Survey of Persons 60 and Over in Cuba.  Regarding daily activities, those which show the smallest percentage of persons able to carry out the activity on their own are:  going places far from home and climbing stairs; still, both are over 76%.  Over 93% of older people surveyed were able to carry out a series of activities on their own, which permitted them to remain home alone 8-10 hours a day: eating their meals (if prepared in advance), taking their medicines, getting dressed, bathing or going to the toilet in time. 

We deduce that interaction between various health problems and an increased tendency to develop disabilities is the basis for morbidity in older people. 

Prevalence of disabilities^31,32 increases with age, although most old people lead an independent and active life.  Disabilities are more frequent in women than in men.  Consequently men have a shorter yet more active life expectancy.  This implies that the increased proportion of women in advanced ages leads to an increase in the presence of disabilities.

Table 9.  Competency in Daily Activities.

Activity	Incapable	Aided	Unaided
Going places far from home	2.33	21.41	76.6
Going places near home	1.23	8.88	89.74
Preparing meals	2.58	10.14	87.05
Doing housework	3.17	9.42	87.20
Taking medicines	0.56	5.82	93.46
Eating	0.28	2.05	97.35
Getting dressed and undressed	0.30	3.20	96.38
Climbing stairs	3.86	18.43	77.37
Bathing or washing	0.40	3.82	95.67
Going to the toilet	0.39	2.96	96.42

Source: National Survey of People over 60.  Cuba.  1985

Older people usually present a combination of simultaneous multi-causal problems that can bring about disorders in various organs and systems.  The most common result of these health problems is a loss of independence.  In many older people, their decreased functional reserves are not apparent until a stress factor is introduced.  Most have a function which is more vulnerable than the rest, and therefore, some diseases such as pneumonia and urinary tract infections can manifest themselves in the form of confusion, incontinence, loss of balance and difficulty in walking.

The gradual decline in the physical and mental health status that accompanies the individual aging process, the resulting reduction in an active and healthy life expectancy, reduced participation in or cessation of work, and increased financial dependence on public or private sources--all lead to the conclusion that an increased older population will also lead to an increase in demand for healthcare services.  Due to the fact that most health problems in older people are chronic and progressive in nature, this may well imply significant increases in the cost of health care as well.

Conclusions

Older people as an age group have the highest rate of population growth.  It is estimated that in the near future one out of four Cubans will be 60 or more, and for the year 2015 this group will outnumber that of persons under 15 years of age.  In Cuba, older people represent 13.1% of the general population, but account for the greatest share of morbidity and mortality rates, and are more functionally dependent than younger people.

References

1. Fajardo Ortiz G.  Tercera edad.  Adulto mayor.  In: Centro Interamericano de Estudios de
    Seguridad Social .  El adulto mayor en América Latina: sus necesidades y sus
    problemas médico-sociales.  México, DF: CIESS, PAHO, WHO, 1995:1-11.

2. Rojas Ochoa F.  Estado de salud en la tercera edad .  La Habana: Editorial Ciencias
    Médicas, 1993:40.

3. García de Jalón P.  Envejecimiento: hechos más resaltables que lo determinan.  An Real
    Acad Farm 1996;62(4):565-601.

4. Quintero G, Pérez R, Manresa JA, Devesa E.  Algunos aspectos higiénicos sociales de la
    Gerontología. Rev Cubana Adm Salud 1984:10(3):243-50.

5. Prieto Ramos O, Vega García E. Temas de gerontología.  La Habana: Editorial
    Científico-Técnica 1996:15-29.

6. Composortega Cruz S.  Características generales de la población de la tercera edad en el
    mundo. In: Centro Interamericano de Estudios de Seguridad Social.  El adulto mayor en
    América Latina: sus necesidades y sus problemas médico-sociales.  México, DF:
    CIESS, PAHO, WHO, 1995:13-33.

7. Kinsella K.  Dimensiones demográficas y de salud en América Latina y El Caribe.  In:
    Anzola Pérez L. La atención de los ancianos: un desafío para los años noventa. 
    Washington DC: PAHO, 1994:3-18 (Publicación Científica; 546).

Excerpted from the Spanish original which appeared in RESUMED  Magazine 1999;12(2):77-90