From the Editors

Heart Disease:
When Primary Care Becomes Critical Care

We have dedicated this issue to heart disease in Cuba, representing the non-communicable diseases which now account for the majority of deaths in the country—a pattern similar to that of industrialized nations. Taken together, heart disease and cerebrovascular illnesses accounted for 37.6% of all deaths in Cuba in 1999, with heart attack in the lead. The good news is that the mortality rates for both these conditions have been steadily declining since 1970. However, health authorities say this is no reason to let down their guard, since these diseases still represent a large share of premature deaths in the country: 21.6% of those who die from cardiovascular disorders are under 65. Most of these deaths, say Cuban experts, could have been prevented by minimizing risk factors associated with cardiovascular illness.

Research into heart disease has often led to the discovery of lifestyles smothered in multiple risk factors, responsible for introducing a silent co-conspirator: hypertension. The WHO estimates that there are 600 million people worldwide who have high blood pressure, and Cuban health authorities estimate that as much as one quarter of their adult population suffers from hypertension. Yet, this disease can remain asymptomatic for years even, many times until it triggers heart attack, cardiovascular accident or a related life-threatening crisis. In this issue, we review the Epidemiology of Hypertension in Cuba , and take a closer look at hypertension as one of cardiovascular conditions suffered by a discreet set of health workers (in Cardiovascular Risk Factors in Health Workers ).

While advances in modern drug therapy are to be applauded, notes Dr. Peter Sleight, president of the World League on Arterial Hypertension, the real battle is on the prevention front. The prime emphasis placed on this aspect in the Cuban National Program for Hypertension (see Spotlight on Cuba's National Program for Hypertension , and MR Interviews ) elicited praise from Dr. Sleight during a June visit to Havana. "It is a great strategy," he commented here in Havana in June, "since although we have good medicines, prevention is the most important thing."

Cuba's family doctor-and-nurse primary care model, which has brought these teams to virtually every Cuban community, offers the kind of grid which facilitates epidemiological risk-factor surveys; public health education; and effective detection, treatment and control of hypertension and other cardiovascular diseases, as well as emergency services for heart attack victims. We draw your attention to Pre-Hospitalizaton Thrombolysis Using Cuban Recombinant Streptokinase , a remarkable seven-province preliminary report on the use of Cuban-manufactured streptokinase in primary care emergency services.

The primary care grid as an important foundation for epidemiological research is reflected in Mortality from Ischemic Heart Disease in Cuba , in which medical researchers gathered data leading them to warn health authorities that positive dietary changes do not appear to be having the expected impact in reducing mortality from this illness, challenging the health system nationwide to pay more attention to detecting other possible risk factors.

Finally, we recommend A New Approach to the Comprehensive Treatment in Cuba of Children with Cardiopathies , which exemplifies the results of efforts to integrate primary, secondary and tertiary-care services to benefit children with congenital heart conditions.

And on other fronts, please turn to What's New at MEDICC for an update on summer programs and a preview of the October symposium in Cuba entitled A Gender Perspective: Vital for Human Development . MEDICC co-sponsors that event with the Cuban Society of Family Medicine and a host of Cuban and international organizations. We are offering a special diploma course to students who attend, and an extra-curricular program for working professionals from the USA and Canada. Participants in both will travel to Havana and Santiago de Cuba. We invite you to join us!

Gail Reed
Editor

Michele Frank, MD
Associate Editor