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Cuba Health News

Cuba’s Aging Pains (and Gains)

By Gloria Giraldo, MPH

June 10, 2007 - With difficulty, 70-year old José García rises with the help of his cane, slowly walking to meet his longtime wife in a soft embrace.  They fall easily into the bolero rhythm already flowing; the cane now rests near a chair - dancing gracefully, his owner no longer needs it.  This transformation takes place one Friday afternoon per month, where a Grandparents Circle meets at the Community Mental Health Center in Regla Municipality, a ferry ride across Havana’s Bay.  

Scenes like these are common throughout Havana, this aging colonial city whose inhabitants are following suit: the elderly population[1] of the City of Havana constitutes 18% of its 2.2 million residents,[2] and some Havana municipalities have the highest concentration of elders in the country. The city’s most aged municipality is Plaza, where 25% of residents are over 60.[3]  This municipality foreshadows the future of Cuba: on its way to becoming one of the oldest societies in the Americas, it’s projected that 1 out of 4 Cubans will be over the age of 60 by the year 2025.[4]  Today, Cubans over 60 constitute 16% of the population.[5] 

The human experience of aging is not merely an individual or nationwide process, but also a global one: very soon, for the first time in history, people 65 and over will outnumber children under 5.  The graying of the population has been widely discussed in the developed world, but the most rapid increases in the 65-and-over population are occurring in developing countries, which will experience a 140% increase by 2030.  A unique feature of aging in developing countries is the very speed of this demographic shift.  For example, it took more than a century -- between 1865 and 1980 -- for France’s 65-and-over population to increase from 7% to 14%.[6] 

Grandparents Circle "Love for Life,” Vedado Municipality, Havana

Cuba is undergoing this same process, which appears to be taking less than 40 years; Cuba’s over 65 population reached 7% in the mid-1970’s and is currently 11% of the total.[5]  In addition to this “compression and acceleration of aging,” lower levels of economic development in countries like Cuba accentuate challenges inherent to the aging process. Former Director General of WHO Gro Harlem Brundtland shot to the heart of the matter when he said “we must fully understand that while developed countries became rich before they became old, developing countries will become old before they become rich.”[4] Thus, poor developing nations must adapt quickly to accommodate the emerging age structure. 

How Cuba Grew Old

The aging process of the Cuban population started at the beginning of the 20th century. There were 72,000 people over the age of 60 by 1900, but by 1950, the number had risen to 425,000.  By 1990, the country had more than one million people over 60, adding approximately 250,000 per decade.[7] 

The total Cuban population now stands at 11.2 million and the crude birth rate is 11.7 per 1,000 (the lowest in Latin America).[8] Indeed, the population growth rate is already -0.43[9] due to low fertility rates since 1900, despite a brief surge in the 60’s. Importantly, since 1978, rates have fallen below demographic replacement levels.  Another demographic indicator, life expectancy at birth, was 52 in the 1950’s for the Caribbean as a whole, increasing to 68 by 2000.[4]  But in Cuba, life expectancy at birth was 56 in 1950,[6] reaching 70 by 1971 and is currently at 77 (75 for men and 79 for women).[9]

Changes in life expectancy reflect a health transition occurring around the world at different rates and along different pathways.  In Cuba, the proportional increase of older adults is not only the result of low fertility rates, but also a decrease in all-age mortality – that is, people are living healthier, longer.  Fewer than 50 per 1,000 people over age 60 die annually in Cuba.[2] Similarly, the average life expectancy of a 60-year old Cuban is 22 years – the same life expectancy for a 60-year old in a developed country. Of particular significance is the increase of the oldest old, defined as people 85 and over:  globally, this group constitutes 7% of the world’s 65-and-over, 10% in developed countries and 5% in developing countries.[6] In Cuba, the oldest old constitute 8.5% of the elderly population.[5]

How is Cuba Coping?

According to the International Union for the Scientific Study of Population’s Panel on Aging in Developing Countries, the majority of developing countries do not have the infrastructure to cope with changing demands from a growing elderly population. Thus, in almost all cases, the highly compressed aging process will take place alongside weak economic performance and changing intergenerational relations, and within fragile institutional contexts that limit access to goods and health services.[10]  

The Cuban elderly have benefited directly since the creation of the National Health System (NHS) in the 60’s, when access to medical services was extended to the entire population. According to Dr Jorge Hadad, Professor in the Aging and Public Health Master’s Program in Havana, the health system is a work-in-progress, continuously reshaping itself to address emerging health issues. Today, aging of the population is that issue. At the end of the 70’s, early evaluation regarding the needs of older adults started emerging in the public health sector.  By 1982, when the Vienna World Assembly on Aging took place, Cuba’s National Plan for the Care of the Aging Population had already been conceived.  On the direct health care provision side, the first geriatric medicine ward opened in 1985; hospitals throughout the country soon followed suit.  At this stage, training human resources specializing in gerontology and geriatrics was prioritized.

The mid-1980s was a fertile period for community-based health programs in Cuba, including those directed at older adult health. In addition to the family doctor-nurse teams serving in every community, Grandparents Circles (Círculos de Abuelos) and Orientation and Recreation Groups or GOR’s (Grupos de Orientación y Recreación), were created at this time.  The Grandparents Circles, supported by the National Sports and Recreation Institute (Instituto Nacional de Deporte y Recreación, INDER), provide space for older adults to participate in physical activities, while the GORs offer field trips, arts and crafts, literary and acting workshops, movie debates, and health education and prevention activities.  Grandparents Circles practicing Tai Chi in parks have become a typical part of the early morning scenery in cities around the country. By the end of 2006, there were 14,738 Grandparents Circles with 782,065 participants representing approximately 43% of the elderly population.[9] 

Municipality Plaza Orientation and Recreational Group

In 1992, the Research Center on Longevity, Aging and Health (Centro de Investigaciones sobre Longevidad, Envejecimiento y Salud, CITED) was founded to strengthen research on aging and longevity; the Comprehensive Care Program for Cuban Elders (Programa de Atención Integral al Anciano Cubano) was launched the same year.  This program re-structured services for older adult care in a three-pronged approach: community-based care, institutional care, and hospital-based care.  Community-based care is centered at the local polyclinic where a Multidisciplinary Gerontological Care Team (Equipo Multidisciplinario de Atención Gerontologica, EMAG) comprised of a doctor, social worker, nurse, and psychologist (all with specialized geriatric training) treat fragile older patients.  Older adults are assessed at the family doctor-nurse office and classified according to a national fragility assessment tool measuring psycho-social and physical functionality.  Similarly, mental health assessments and care are coordinated through community-based mental health centers. 

The main goal of the Comprehensive Care Program is to preserve and optimize the health of older adults and maintain their capacity to continue living in their communities. According to demographer and Professor at the National School of Public Health, Dr Aida Rodríguez, Cuban culture and its social organization, although changing, still encourage and support keeping seniors within the family environment. She adds that “adult children feel a strong responsibility to reciprocate – to provide their aging parents with the care and support they received earlier in life.”  Similarly, University of Havana psychologist Dr Patricia Arés emphasizes that grandparents in general, and grandmothers especially, play a pivotal role in their families, providing significant childcare assistance According to the Ministry of Public Health’s Division for Older Adults, only 0.44% of older adults are currently institutionalized (7,803) and 78% of older adults (140,176) living alone receive home care.[9] Finally, Cuban health professionals speak of the need for geriatrization of all health services – in other words, not necessarily creating new and separate spaces for older patients, but cross-training all health personnel to provide integrated care to geriatric patients in their regular practices. 

Beyond Gardening and Dominoes

Seniors University Program at Havana University, School of Psychology

An interesting aspect of Cuba’s aging process is the makeup of the aging population: since 1959, unprecedented access to higher education opened the door for an entire generation of Cubans to become the first college graduates in their families. Thus, an important segment of those turning 60 now had a very different life experience from their forbearers.  Today, addressing the needs of a highly educated aging population presents new challenges, requiring innovative programs to fulfill the needs of seniors who demand a higher level of intellectual stimulation.

The Seniors University Program, for example, created in 2000, provides an opportunity for personal development, updating and upgrading knowledge, plus social involvement. In 2006, there were 927 year-long courses throughout the country and 43,000 participants had graduated.[11] Havana University Professor and President of the Seniors University,Teresa Orosa explains, “there are many seniors who, after they graduate [from the year-long course], take a ‘post-graduate course’ and become leaders or facilitators in their own communities.  And some continue to work on a thesis project related to an aging issue of their choosing.”  A group of seniors participating in the program told Cuba Health Reports that they want to understand aging in their own terms, and re-define aging from their own perspectives as seniors.  Dr Hadad adds that “medical practitioners, psychologists, and scientists in related fields have been able to reach a very deep understanding of human development up to adolescence, but there’s a gap in understanding around the aging process and the psychology of aging.”  In Cuba, as elsewhere, older adults want to play a protagonist role in defining the aging process, demystifying long-held beliefs that regard old age as a period of deterioration and stagnation. 

 Looking Ahead to a Graying Future

According to Associate Professor Liliana Gómez from the Institute of Medical Sciences in Camagüey province, this is just the beginning. “My generation, those of us who are in our mid-40’s and will reach 65 by 2025, will surpass the educational level of the current generation, and the demographic characteristics will differ even more from today’s elders.  Many women my age chose not to have children, and the reduced nuclear family will be even smaller than today’s; our needs will be very different.  How those needs will be met is our great challenge, and as a society, we need to start planning for our own future.”  It seems that future is now: the often-quoted 25% who will be over 60 by 2025 is a current reality for some municipalities. And problems including substandard and inadequate housing, which force multigenerational families to share and negotiate very limited spaces; aging buildings and streets that pose architectural barriers; lack of transportation options; the retirement of large numbers of people by 2020; and long-term care needs of the elderly will be extremely burdensome for Cuba’s social system.

Cuban society is well aware of the implications of this collective aging process, which is further complicated by the aforementioned country’s negative population growth rate. In economic terms, this means that a third of the population will have to support the rest of society, according to urban planner and local development expert Miguel Coyula.  The growing number of retirees and pensioners reached approximately 1.5 million in 2005,[12] causing government to dedicate over 10% of Cuba’s GNP just to keep social security functioning, adds Coyula. 

While Cuba's aging indicators mimic First World demographics in a Third World economy, the country's overall aging process and its challenges resemble those gathered in the recent report by the US National Institute of Aging, Why Population Aging Matters: A Global Perspective:[6]

• The overall population is aging;
• The number of oldest old is rising;
• Non-communicable diseases are becoming a growing burden;
• The population will shrink in a few decades;
• Family structures are changing;
• Patterns of work and retirement are shifting;
• Social insurance systems are evolving; and
• New economic challenges are emerging.

To address these challenges, Cuba is seeking solutions within its institutions and people.  As students in a Seniors University course at Havana University told Cuba Health Reports, “there is a need to create a gerontological culture -- not only to develop spaces for seniors to do arts and crafts, gardening and physical activities -- but also spaces where seniors can participate actively, proposing innovative solutions to the challenges of aging and contributing to creating the world in which we want to age.” 

Given Cuba’s community- and problem-based health approach, which has led to robust health indicators nationally (see Cuba Health Data), and considering that it will be one of the first developing countries where elders outnumber children within families, the world will be watching this evolving health story.  You can too: visit Cuba Health Reports soon for the second installment of “Cuba’s Aging Pains (and Gains),” where topics such as Cuba’s centenarians, long term care and institutionalization, active aging, and the role of aging women will be explored. 

Notes & References

1. Data from Latin America and the Caribbean, including Cuba, are for age group 60 and over. North American and global data are for age group 65 and over.  This article utilizes both according to source document.
2. Ministerio de Salud Pública. Anuario Estadistico de Salud de Cuba 2006. La Habana 2007. Digital Version.
3. Cardenas, Mercedes MD, Coordinator of the Multidisciplinary Gerontological Care Team of Moncada Policlinic, Plaza Municipality. Personal Communication on May 9, 2007.
4. Economic Commission for Latin America and the Caribbean. Population Ageing in the Caribbean:  An Inventory of Policies, Programmes and Future Challenges; 2003 [cited 2007 April 10]. Available from:  http://www.cepal.org/cgi-bin/getProd.asp?xml=/publicaciones/xml/4/14384/P14384.xml&xsl=/portofspain/tpl-i/p9f.xsl&base=/socinfo/tpl/top-bottom.xslt
5. GeriCuba [Homepage on the Internet]. Havana. Cuba; c1999-2007 [updated 2007 May 19; cited 2007 April 2007]. Available from: http://www.sld.cu/sitios/gericuba/temas.php?idv=13176
6. National Institute on Aging; National Institutes of Health.  Why Population Aging Matters:  A Global Perspective.  March 13 2007. Washington, DC. Available from:  www.state.gov/g/oes/rls/or/81537.htm
7. Centro Iberoamericano de la Tercera Edad (CITED). Atención del Anciano en Cuba: Desarrollo y Perspectiva. La Habana, Cuba, 1996.
8. Economic Commission for Latin America and the Caribbean [Homepage on the Internet] Available from:  http://www.eclac.cl/Celade/publica/bol62/BD6204.html
9. Oficina Nacional de Estadísticas (ONE). Anuario Estadistico de Cuba 2005. La Habana, 2006.
10. Fernandez, A.  Aging in Cuba.  XV Seminario Internacional Atención al Adulto Mayor, Havana; May 7–10, 2007.
11. International Union for the Scientific Study of Population Panel on Aging in Developing Countries [Homepage on the Internet]. Available from:  http://www.iussp.org/Activities/aging-index.php
12. Orosa, T. La Catedra del Adulto Mayor. XV Seminario Internacional  Atención al Adulto Mayor, Havana; May 7–10, 2007.

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