Cuba Health News

Turning the Tide on Cancer in Cuba

By Conner Gorry & Gail Reed

June 20, 2007 – “Cancer control is as complex as it is urgent,” states Dr Teresa Romero, Director of Cuba’s new National Cancer Control Unit. The straight-talking Romero, responsible for coordinating the country’s strategy to rein in Cuba’s #2 killer, harbors no illusions about the job at hand for her and her colleagues. Indeed, this is not only a Cuban problem: in 2002, 6.7 million people died from cancer and that number is estimated to rise to 10.1 million by 2020.[1]   What may surprise some is that by 2005, 80% of annual deaths from chronic diseases like cancer were in poor countries, not rich ones.[2]

The Unit headed by Dr Romero is the Cuban health system’s first attempt to bring under one coordinating agency all cancer control activities, and harness the human, financial, and technological resources needed to address each locale’s particular cancer picture.  This involves a colossal organizational effort, coordinating prevention, screening, diagnosis, treatment, and palliative care throughout the country.  It requires bringing together the experts, experiences, and evidence-based research to “convert processes and results into standards that benefit public health – without bureaucracy or delay,” Dr Romero told Cuba Health Reports.

Implementation of the new program turns on two main strategies:

1. Efficiency and effectiveness in design and execution; and
2. A methodologically sound process, so that the experience might be applied in other countries of the region.

The Data: A Snapshot of Cancer in Cuba

Cuban public health authorities have been tracking cancer’s rise as a cause of death and years of potential life lost (YPLL), revealing that malignant tumors are now the leading cause of death in some provinces, and the number two nationally (Table 1). Furthermore, malignant tumors are the number one cause of YPLL, a trend that has been rising over the past 20 years (Table 2). The main problem, however, has been the state of the national cancer program following more than a decade of extraordinary economic hardship after the collapse of the socialist bloc in the early 1990s. Known as the Special Period, 85% of Cuba’s foreign aid abruptly vanished, adversely affecting, among other things, the health system’s ability to systematize its efforts to monitor, control, and manage chronic diseases such as cancer.

Table 1: Crude Mortality Rates by Cause & Province, 2006 (per 100,000 population)

Source: Ministerio de Salud Pública. Anuario Estadístico de Salud de Cuba 2006.

Table 2: Years of Potential Life Lost (YPLL) by Cause, Selected Years (per 1,000 population)

*Hipostatic bronchopneumonia was not included in years 1975 & 1985.
Source: Ministerio de Salud Pública. Anuario Estadístico de Salud de Cuba 2006.

According to Romero, “equipment had deteriorated and was failing, medicines were scarce, and buildings were in disrepair. And while we couldn’t recover from that all at once – buying technology, equipment, medicines and the rest – we realized we could and should integrate and coordinate all our services to be better positioned for when we could finally make the necessary financial investment.” But acquiring the latest technology means more than just allocating money: it also means training Cuban specialists and technicians to use, maintain, and repair it, Romero observed.

The Grand Plan & How it Works

A total of 248 general, clinical/surgical, pediatric, and other specialized hospitals provide medical attention throughout Cuba’s 14 provinces and the Isle of Youth. Some 470 community polyclinics provide primary care services in the country’s 169 municipalities.[3] Simply mapping all the activities targeting cancer throughout the health care network is a challenge; coordinating them is an enormous undertaking. The Unit is tackling this responsibility in four phases:

1. Coordinate collaborating centers throughout the country under the Unit’s umbrella to establish the Cancer Observatory.
2. Pilot cancer control and coordination programs in 30 polyclinics in Havana City province, eventually to be extended throughout the country.
3. Share knowledge from pilot program results and extend program to the municipal level nationally.
4. Integrate non-health care centers and institutions working in the field of cancer control.

Phase 1: Mapping the prevalence, incidence, and distribution of different types of cancer throughout the country and the specialists and services available in each locale. This seminal effort is being pursued through the Cancer Observatory, a dynamic, informational registry using concepts similar to PAHO’s Observatory of Human Resources in Health and front-line health information technologies (HIT) to collect and analyze data from around the country (see Table 3).

This mapping will facilitate more agile and pro-active responses to the cancer problem nationally, says Dr Romero, by providing an important tool for tailoring cancer control. “Cancer is not uniform – it varies from place to place and person to person. With three dimensional mapping and the Observatory, we can learn what type of cancers a hospital is seeing, what capacity they have to diagnose and treat, what specialists they need and how they need to be trained,” Romero told Cuba Health Reports.  

The Observatory mechanism is also important for active knowledge sharing of diagnoses and eliciting second opinions, specialist consultations, real-time debates over distances, and coordinating services. “Not everything pertaining to cancer control is happening in Havana: there are innovative experiences and methods in the provinces as well. Free-flowing information will help us identify synergies and ultimately improve our work,” Dr Romero says. Such evidence-based analyses also serves to inform human and financial resource allocation and planning, which dovetails with the Cuban health system’s strategy for bringing services closer to the populations in need, while managing the economics of health.  The Unit is also employing HIT for long-distance education purposes.

Table 3: Crude Cancer Incidence by Province, 2003

Source: National Cancer Register, Havana, Cuba, 2005.

Phases 2 & 3: Cancer control initiatives planned for Phase 2 include active screenings for breast, cervical-uterine, and mouth cancer (prioritized due to prevalence) in the healthy population of Havana City. Screenings will be extended to all 14 provinces and the Isle of Youth.  In Phase 3, active screenings for breast and cervical-uterine cancer – again, prioritized due to prevalence – will be conducted in the healthy population in each of Cuba’s 169 municipalities.

To achieve a successful rollout of these phases requires procuring the right technology, and innovating where necessary. For example, Dr Romero concedes that there is currently not enough mammography equipment to screen everyone, everywhere. Since it is not practical economically to buy single machines for every small community throughout the country, the Unit is considering mobile equipment, once used in some parts of Cuba. “This will require logistical coordination,” says Romero, “but will ultimately be more practical and make more economic sense.”

Yet, technology acquisition is easier said than done: the US economic embargo against Cuba means the country cannot buy equipment or replacement parts from US companies or their subsidiaries without a specific license from the US government. Nor can Cuba buy freely from firms in other countries if the equipment has 10% US parts.  This often obliges health authorities to purchase technology from suppliers farther away, driving up prices on already costly technologies. (For more: The Impact of the U.S. Embargo on Health and Nutrition in Cuba).

Phase 4: The Unit proposes to build on the health system’s already significant level of integration among institutions, research centers, and stakeholders, extending this to agencies outside the health sector. Dr Romero cites examples such as educational campaigns in primary schools designed with the Ministry of Education and the annual Terry Fox Run Against Cancer co-sponsored by the National Institute for Sports and Recreation (INDER) and the Canadian Embassy. Phase 4 of the program’s development will expand this kind of collaboration to other institutions, including Geocuba, whose cartographers are already at work on the aforementioned Cancer Observatory.

Cuba’s Secret Weapon

The most powerful tool in the control of cancer, says Dr Romero, is not cutting edge technology or a phalanx of specialists, but rather the Cuban family. Working together with their primary care doctors and nurses, families are the first line of defense. Dr Romero elaborates: “here as elsewhere, the real fight against cancer – like other chronic diseases – is fought with early detection, prevention, and health promotion. The cornerstone of that is the family, and the family is what brings our entire strategy together.” She cites a healthy home environment, with a nutritious diet and good habits as examples of fundamental prevention components. Likewise, Dr Romero notes, any change in health or well being (e.g., a suspicious mole, malaise, weight loss, etc) is likely to be noticed first by a family member.

Being a positive role model for young children and adolescents is another way parents, older siblings, and teachers can have an appreciable effect. Unfortunately, too many Cuban role models still smoke (women especially), drink alcohol to excess, and are sedentary; these are areas where the country needs to get more aggressive (see Table 4 for national lung cancer rates). In fact, most cancer in Cuba, as in other parts of the world, is caused by three factors: tobacco use, poor diet, and lack of exercise.  Obesity, in particular, is of increasing concern in Cuba, where a recent report found 10.2% of children are overweight and 8.8% are obese.[4]

Table 4: Lung Cancer Rates in Cuba by Age and Gender (per 100,000), 2003

Source: National Cancer Register, Havana, Cuba, 2005.

But it’s a process based on education and individual agency leading to lifestyle changes. Cuban law (Resolution 335/04 of February 2005), for example, prohibits smoking on buses, trains, in baseball stadiums, offices, restaurants, and other public spaces[5], but some people still smoke in these places. Worse, their seatmates, neighbors, and co-workers too often let them get away with it. The same Resolution requires stores selling cigarettes to post a sign prohibiting sale to minors, but it’s not uncommon to see Cuban children buying a pack of Populares for mom or dad. In order to reverse the smoking trend in Cuba, which has a long, illustrious history tied to tobacco cultivation, the Cancer Control Unit is working with the University of Havana’s Communications Department on a family-specific anti-smoking campaign. This cannot take effect too soon, according to Dr Romero. The American Cancer Society would agree: “tobacco use is the number one cause of cancer and the number one cause of preventable death throughout the world.”[6]

It will be a long time before lifestyle changes and other initiatives spearheaded by the Unit will start to affect indicators, but Dr Romero is hopeful. “Despite the challenges and the indicators – which can get you down if you let them – we’re optimistic that we’ll be able to reduce cancer in Cuba.”

Notes & References

1. American Cancer Society. Cancer Facts & Figures, 2007. Atlanta: American Cancer Society; 2007.
2. World Health Organization. Preventing Chronic Diseases: A Vital Investment. Geneva: World Health Organization; 2005.
3. Annual Health Statistics Yearbook, 2005. Ministerio de Salud Pública, Dirección Nacional de Estadística, 2006, La Habana.
   Available from: http://www.medicc.org/resources/documents/Anuary%20Cuba%202005.pdf
4. Giraldo, G. Obesity: A Growing Problem in Cuba. Cuba Health Reports. 2006 December 1.
   Available from: http://www.medicc.org/publications/cuba_health_reports/007.php
5. Gorry C. Running for a Cure: Terry Fox Inspires Cuba. MEDICC Review. 2005 May;7(5):32.
   Available from: http://www.medicc.org/publications/medicc_review/0505/headlines-in-cuban-health.html
6. American Cancer Society. Cancer Facts & Figures, 2007. Atlanta: American Cancer Society; 2007.

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