Interviews

Orlando Landrove, MD
National Coordinator, Programs for Non-Communicable Diseases Cuban Ministry
of Public Health

Unlike most developing countries, the main causes of death in Cuba are now chronic, non-communicable diseases. In fact, heart disease, cancer and cerebrovascular accidents account for almost two-thirds of all deaths in the country. This gives particular relevance to the Ministry of Public Health's programs for the prevention and control of such conditions. In addition to the three major life-takers already noted, there are also programs to address asthma and diabetes; attention to the elderly; and to reduce accidents, smoking and alcoholism.

Dr. Orlando Landrove heads efforts to formulate, periodically revise and evaluate each of these major undertakings of the Ministry.

MR: Dr. Landrove, can you tell us how the programs are developed in the first place, and to what extent they are applied across the country?

OL: Let me start by answering the last part first: each of these programs is intended for application at all levels of Cuba's national health system, from the primary or community level up to the tertiary level of medical attention. Thus, when we evaluate how they are working, we also assess their practice at all levels.

The process of developing the programs has evolved over time. At one point, we perhaps relied more exclusively on "commissions of experts". Today, we bring in a much broader array of opinion. We first review the international literature, and reflect on the current epidemiological situation in Cuba regarding the particular disease and our experience thus far in prevention and treatment. Then, we bring together experts in the field, but also in other related fields, as well as family doctors from the primary care level. Our focus is multidisciplinary, and so the working group will also include epidemiologists, farmaco-epidemiologists, clinicians of various types, nurses, and when necessary psychologists, social workers and other health professionals.

After we have a draft in hand, then we consult nationwide, a process which clearly enriches the program with experience across the island.

Once the program is in final form—including norms for its implementation—then we periodically review it based on national assessments of its performance. For example, in the case of the National Hypertension Program, we held a national evaluation workshop in June of this year, in the context of the First Cuban Congress on Arterial Hypertension and the 4^th Caribbean Scientific Event on the same theme.

MR: What were the results of this assessment? Where have you made progress? What are the weak points?

OL: Clearly we have made progress in detecting hypertension in the population: we now record 16.4% of the adult population (over 15) as suffering from hypertension. However, we still have a ways to go, since we estimate that the real figure hovers at about 25%. Key to increasing detection over the next period is the fact that we have already given special "refresher" training in the program to over 90% of medical personnel across the country.

Another area where we see advances is in a greater coherence in application of therapies for this condition. Some time ago, therapeutic criteria were dispersed, less consistent. But as a result of a richer debate on therapies, and the more persistent attention to this problem brought about by the national program, a consensus has developed regarding therapeutic options—placing the first priority on changes in lifestyles, for both prevention and therapy; and then moving to reliance on single drug therapy or multiple when necessary, beginning with beta blockers and diuretics. But that said, I would also have to add that we need to give better, higher quality attention, to hypertensive patients, which is the only way to educate them and bring conscious change in their living habits.

MR: What are some of the particular risk factors for hypertension among the Cuban population that the Program addresses?

OL: One particular risk factor is the aging of the population, both because of reduced fertility rates and greater life expectancy. Second, sendentary lifestyles primarily associated with the urban population. In this regard, one of the only positive results of the economic crisis in Cuba has been decreased obesity, but we still have to pay close attention to this aspect since nutritional habits are difficult to change. For example, many Cubans would rather cook with lard than vegetable oil, despite the clear health risks.

The ethnic combination of the Cuban population, in which there is a strong presence of our African heritage, also alerts us to a greater risk of hypertension.

And finally, certain other habits, and in particular smoking, are clear cause for concern.

MR: Now that you have mentioned it, let me ask you what is being done to reduce smoking in Cuba? Given that Cuba's tobacco is sought out worldwide, the habit must be even more tempting here on the island itself.

OL: Absolutely, and we have a very high percentage of smokers, especially among men and young men. But we have a recent governmental agreement to assist the Public Health Ministry in generating stronger national anti-smoking campaigns, in addition to the prohibition that already exists on cigarette advertising. Cuba is also one of five Latin American countries participating in PAHO's "CARMEN Network" (Ed.note: CARMEN is the Spanish acronym for Combined Actions for Multi-factorial Reduction of Non-Communicable Diseases). Cienfuegos Province has been selected as the pilot area for the program, which places considerable emphasis on reducing smoking among the population. We are also adopting the "Quit and Win" campaign which has been so successful in Europe, and television spots have begun airing this month to supplement those which we have been broadcasting for some time, which present the dangers of smoking during pregnancy, teenage smoking and secondary smoke.