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chikungunya Cuba

When Nature Calls: Cuba’s Public Health Infrastructure Exposed.

Sherri L. Porcelain*

A disaster will not spontaneously trigger an outbreak of disease, unless, of course, a highly infectious disease such as Ebola is the reason for the emergency event. Countries are vulnerable to both newly emerging and remerging communicable diseases when collapsing infrastructure and continuing neglect threatens the health of residents and tourists visiting the country.

Cuba’s current challenges with cholera, dengue, and its viral relative, chikungunya, are good examples. Cholera and dengue continue to spread throughout the island, while the Cuban government claims that all the reported cases of chikungunya have been imported to the island from Haiti and the Dominican Republic. According to the Pan American Health Organization’s (PAHO) Update on Chikungunya Fever in the Americas (August 8, 2014), Cuba has officially reported 11 imported cases with no suspect or confirmed locally acquired cases since the start of the outbreak in the Americas. (1)

Chikungunya, a viral disease transmitted by an infected mosquito, has reached this hemisphere for the first time in history in December 2013 when it arrived on the Caribbean island of Saint Martin and spread throughout the region. Recent data shows local transmission of chikungunya has been identified in 29 countries and territories in the Caribbean, Central, South and North America, including the United States with a cumulative total of 508,122 suspected and 5,271 laboratory-confirmed cases, as of August 1, 2014. (2) Cuba rebuffs what independent journalists, rumors, and local health professionals describe on the island.

Here we go again.

Most likely Cuba’s failure to report chikungunya is intentional and not due to poor data gathering capabilities. Cuba has an advanced epidemiologic surveillance system with highly skilled scientists and dedicated health professionals. However, the government’s failure to release timely outbreak data threatens health security today.

A brief discussion on the relationship of climate change, failing infrastructure, and the frequency and intensity of natural disasters is considered below to identify both the challenges and realities with such diseases as cholera, dengue, and chikungunya in Cuba.

Climate Change

Scientists project that climate change will impact both the frequency and intensity of extreme weather patterns. The Caribbean region, and islands like Cuba, could expect rise in sea levels, and this combined with more intense weather events will make flooding more common.

Cuba’s coastal regions will be impacted the most, however, Cuba could experience protracted seasons of both droughts and flooding, and reliable potable water could become scarce.

According to José Rubiera, top Cuban Meteorologist, the “seawater temperature is rising and the conditions in the upper atmosphere are favorable to rapid intensification. These cases are now somewhat more frequent; it means something is changing.”(3)

The vibrio cholera bacteria has been known to survive in brackish waters and estuarine environments, attaches to zooplankton and moves along the ocean currents as it is carried into new areas,(4) continuing the threat to Cuba and Hispaniola.

This danger is especially problematic in countries where fragile water, sanitation, sewage, and housing systems are further threaten by climate change and rising water temperatures where the multiplication of the cholera bacteria has been documented.(5)

Infrastructure

Even though Cuba’s official reporting on their health status indicators match developed world measures, I suggest that the earlier investment in the Cuban public health infrastructure is eroding quickly and without greater attention, the likelihood of infectious diseases spreading spatially and temporarily will continue.

As reported in New England Journal of Medicine article earlier this year, the reality is that, “Any visitor can see that Cuba remains far from a developed country in basic infrastructure such as roads, housing, plumbing, and sanitation.” (6)

According to Relief Web, PAHO warned Cuba a week before Hurricane Sandy (October 2012) struck that further damage to the sanitation system could be problematic in the areas previously affected by cholera and other illnesses related to water use and handling of food.

It is no surprise that “Drinking water is contaminated in most Cuban cities,” and neighborhoods have ongoing problems with sewage in the streets. (7)

Let’s not overlook the poor hygienic conditions in hospitals and clinics. Cuban independent journalists along with dissident physicians have described water and vector borne disease outbreaks associated with the government’s failure to meet basic sanitation standards. (8)

Current water treatment facilities seem to lack the chemicals, equipment, and appropriate filter units, along with the inconsistent availability of chlorine for safe water. (9)

Furthermore, a failure to maintain continuous water pressure will hinder the amount of water and contributes to the contamination of the water supply. (10)

Lastly, a valuable engineering report on Cuba’s infrastructure reminds us “more than 50% of the water pumped through the distribution system is lost due to leaks in deteriorated piping.” (11)

Natural disasters

Based upon what we know about climate change and infrastructure demands in Cuba, the vulnerability and hazard reduction strategies associated with natural disasters are especially important with high winds, surging seas, and flooding. Hurricane season begins June 1 through November with October and November recognized as the most active times for cyclones to strike in Cuba.

Fifteen hurricanes and two major storms have struck Cuba since the new millennium. The greatest risk for landslides is located in the eastern provinces where earthquakes also have a higher likelihood of threats.

While Cuba has a well-developed emergency evacuation and response plan, they show a poor performance in disaster reconstruction, recovery, and mitigation. (12) This is evident as the battering of their public health infrastructure continues to decline.

According to researchers the most “troublesome is the lack of meaningful official programs to attempt to minimize or mitigate the damage that is caused by the severe vulnerability of the built environment to the hazard agents of hurricanes and earthquakes,” (13)

Hurricanes Michelle (November 2001), Isadore (September 2002) followed by Lily (late September 2002) presented national challenges.

However, it was Hurricanes such as Charley (August 2004) which became the most destructive to strike Cuba’s western Havana region since 1914 followed by Ivan (September 2004), the first Category 5 hurricane to hit Cuba in 80 years. This battered Pinar del Rio, Cuba’s most western region, which has been more regularly impacted by hurricanes.

The 2005 hurricane season was very active with Dennis (July), Rita (September), and then Wilma (October) reporting the worst death toll in Cuba in more than 40 years.

After some quiet hurricane seasons, Gustav (August 2008) a Category 4, and weeks after tropic storm Fay hit, became the strongest storm in 60 years with an estimated $5 billion to damage to medical facilities, schools, infrastructure, crops and livelihood. (14)

Hurricane Ike (September 2008) reported hundreds of water wells in rural areas damaged, dams overflowing, and more than 1 million without potable water.

U.S. engineers report that the “water supply system is unstable because pumps are in need of repair and because of frequent interruptions in the electrical supply needed to run the pumps,” (15) which is especially challenging during hurricane seasons.

Hurricane Sandy (October 2012) hit the eastern region leaving devastation in Santiago de Cuba and Holguin while threatening highly populated communities and destroying critical public health infrastructure.

In 2013, Ricardo Mena, a United Nations official responsible for disaster risk reduction in the Americas announced that “Cuba has enormous amount of deteriorated buildings that can't withstand natural disasters." (16)

While Cuba has a well-developed disaster response system, the foundation to protect its people continues to crumble and expose the fragility of the water, sanitation, sewerage, housing and road systems. Rising sea levels, flooding, warming temperature, and the number and frequency of emergency events are expected to create both water-borne and vector-borne diseases threats in the 21st century. So if we want to blame Cuba’s recent problems on climate change, natural disasters, or other reasons it doesn’t matter. What matters is protecting the health of the country’s residents and visitors. This must begin by reminding the international community that Cuba's silence on disease outbreaks (17) -along with their deteriorating infrastructure- could wreak havoc when nature calls.

Notes

(1) PAHO Epidemiology Week Report on Chikungunya to Date (Week 32), August 8, 2014.

(2) Center for Disease Control and Prevention (CDC), Chikungunya in the Americas http://www.cdc.gov/chikungunya/geo/americas.html, accessed August 8, 2014.

(3) Patricia Grogg. Hurricanes Getting Stronger in the Caribbean, InterPress Service, Interview with José Rubiera July 10, 2013, http://www.ipsnews.net/2013/07/qa-hurricanes-are-getting-stronger-in-the-caribbean/

(4) RR Colwell Global Climate Change and Infectious Disease The Cholera Paradigm (1996) Science, 274 2025-2031.

(5) Joan L Aron & Johnathan Patz Ecosystem Change and Public Health: A Global Perspective (2001).

(6) Edward D Campion, and Stephen Morrissey, A Different Model-Medical Care in Cuba New England Journal of Medicine Perspective, January 24, 2014.

(7) Katherine Hirschfeld, Book Review, Linda Whiteford and Laurence Branch’s Primary Health Care in Cuba: The Other Revolution (Rowman and Littlefield, 2008), in Soc (2009) 46:293–296 Published online: 27 March 2009 p. 294.

(8) Katherine Hirshfeld (2009).

(9) Eds. Manuel Cereijo and Helena Solo-Gabriele, Infrastructure Assessment for a Transition in Cuba (March11, 2011), Endowment for Cuban American Studies p. 11.

(10) Ibid.

(11) Cerijo and SoloGabriel (2011), p.12.

(12) B. E. Aguirre and Joseph E Trainor, Emergency Management in Cuba: Disasters Experienced, Lessons Learned, and Recommendations for the Future, in ed. David A. McEntire Comparative Emergency Management: Understanding Disaster Policies, Organizations, and Initiatives from Around the World, http://training.fema.gov/EMIWeb/edu/CompEmMgmtBookProject.

(13) Aguirre and Trainor, p.5.

(14) Canadian Red Cross, Cuba Hurricanes 2008, accessed August 7, 2014

(15) Helena M. Solo-Gabriele and Armando I. Perez Water and Waste Sector: Environmental Literature, Institutional and Economic Issues and Future Work, 378-389, in Infrastructure Assessment for a Transition in Cuba (2008) http://ctp.iccas.miami.edu/InfrastructureAssessment.asp p. 387.

(16) Jean Friedman-Rudovsky. Hurricane Tips From Cuba, New York Times, 30 July 2013: D.6

(17) Luis Rosas Suarez, El silencio epidemiológico y la ética de la salud pública cubana, Revista Cuban de Salud Pública 39(3) (2013), 524-539 and Sherri L. Porcelain Cuba’s Silence is Dangerous to Your Health, ICCAS Focus in Cuba Issue 197, August 5, 2013 http://ctp.iccas.miami.edu/FOCUS_Web/Issue197.htm.

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*Sherri L. Porcelain teaches global public health in world affairs at the University of Miami Departments of International Studies and Public Health Sciences and Senior Research Associate, Institute for Cuban and Cuban-American Studies.

_________________________________________________

The CTP can be contacted at P.O. Box 248174, Coral Gables, Florida 33124-3010, Tel: 305-284-CUBA (2822), Fax: 305-284-4875, and by email at ctp.iccas@miami.edu. The CTP Website is accessible at http://ctp.iccas.miami.edu.


Nota del Editor: Articulo recibido por correo electrónico desde la fuente. 

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Cuba: Chikungunya reported in several provinces.

This past Friday, the Pan American Health Organization (PAHO) reported for the first time, two imported chikungunya cases on the island country; however, it appears that it may be worse than the PAHO reports. Hablemos Press report reported Friday (computer translated), doctors at the Vladimir Ilich Lenin University General Hospital, in the eastern province of Holguín, are reporting cases of chikungunya fever in several provinces including  Guantánamo, Granma, Las Tunas, Santiago de Cuba, and in Havana.
Nota del Editor: Esta informacion toma como referencia el despacho que aparece publicado en Hablemos Press de la prensa independiente cubana. 
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¿Está presente en Cuba la epidemia de Fiebre de Chikungunya?, ¿hay casos reportados?

Una nota periodística desde Cuba firmada por el comunicador independiente, Mario Hechevarria asegura que ya existen casos de  Fiebre Chikungunya en varias provincias del país. Esto contrasta con los informes de la Organización Panamericana de la Salud donde, hasta el 23 de mayo del 2014, NO se reportaban pacientes con esta enfermedad en Cuba. Veamos tres informaciones relacionadas entre sí, en la primera nota que nos llega de Cuba hay una información independiente que incluimos completa:

Por Mario Hechavarria Driggs.

Médicos del Hospital General Universitario Vladimir Ilich Lenin, ubicado en la oriental provincia de Holguín, informaron sobre la existencia de casos de fiebre Chikungunya, en varias provincias del país.

Las salas de emergencia de los hospitales han reportado casos de esta enfermedad al Ministerio de Salud Pública Nacional, según afirmó una de las fuentes médicas, que prefirió mantenerse en el anonimato.

La respuesta del organismo rector del Sistema Nacional de Salud, ha sido habilitar una escuela lejos de la ciudad (en Holguín), para las personas infectadas, con el objetivo de evitar contagios.

Por su parte, las autoridades del gobierno provincial, piden cooperación con la campaña anti vectorial, para destruir los focos infecciosos, pero también mantiene buena parte de la información bajo silencio.

Hasta el momento, se han reportado enfermos en las provincias Guantánamo, Granma, Las Tunas, Santiago de Cuba y La Habana.

Alba Fernández Ortiz, vecina de calle 1ra, reparto Luis Dagnes, en Santiago de Cuba, asegura que, desde hace algunos días, en su cuadra hay varias personas con dolores de estómago, fiebre y diarreas abundantes, pero los médicos les dicen que solo se trata de un brote diarreico, y no informan exactamente si es cólera, dengue o fiebre Chikungunya.

Otros vecinos se quejan sobre las condiciones para la atención a los pacientes, el maltrato del personal hospitalario y la contaminación de las fuentes de abasto de agua para la población, problemas que, de mantenerse, podrían acarrear una epidemia mayor.

Lisván Hernández Sánchez, corresponsal de Hablemos Press en Las Tunas, confirmó que decenas de personas han sido hospitalizadas en esa provincia, debido a un brote diarreico cuyo origen se desconoce.

Señaló que la situación se agrava debido a la postura que mantienen las autoridades al no informar a la población para que tome las medidas sanitarias pertinentes.

La Fiebre de Chikungunya o Artritis Epidémica Chikungunya es transmitida por los mosquitos Aedes aegypti y Aedes albopictus, portadores de la fiebre amarilla. La misma produce dolores en las articulaciones, fiebre alta y, de no atenderse a tiempo, incluso la muerte. Fuente: Hablemos Press –


En el último boletíndel Instituto Pedro Kouri (IPK) la institución más importante en el manejo de las enfermedades infecto contagiosas en Cuba, conocido también cono Instituto de Medicina Tropical , aparece un artículo completo sobre la Fiebre de Chikungunya pero NO señala que esta enfermedad  está presente en Cuba, que los pacientes son diagnosticados y tratados , a pesar de que informadores independientes señalan pacientes diagnosticados en : Guantánamo, Granma, Las Tunas, Santiago de Cuba y La Habana e incluso se ha dispuesto de una facilidad de hospitalización en las afueras de la ciudad de Holguín. Este boletín aparece con fecha 10 de mayo del 2014.

Debemos de suponer que las autoridades de salud en Cuba están tratando de confirmar la información, para poder reportarla a la OPS-OMS, de lo contrario están incurriendo en una práctica de fraude o encubrimiento  en relación a esta enfermedad que afecta a otros países en el Caribe. NO podemos asegurar que esta enfermedad ya sea de declaración obligatoria en Cuba.

También la Organización Panamericana de la Salud (OPS) en su última actualización sobre esta enfermedad publicada con fecha 23 de mayo del 2014 NO reporta casos en Cuba, aunque en este boletín no aparece la tabla de número de casos reportados por países. En este informe podemos leer lo siguiente:
En diciembre 2013 se detectó por primera vez la transmisión autóctona del virus chikungunya en la Región de las Américas. Desde entonces y hasta la semana epidemiológica (SE) 20 del 2014, el virus tiene transmisión autóctona en seis Estados Miembros y nueve territorios en la sub-región del Caribe; Anguila, Antigua y Barbuda, Dominica, Guadalupe, Guayana Francesa, Haití, Islas Vírgenes Británicas, Martinica, República Dominicana, Saint Kitts y Nevis, San Bartolomé, San Martín (Parte francesa), San Vicente y las Granadinas, Santa Lucia y Sint Maarten (Parte holandesa)1. El número de casos sospechosos y confirmados notificados hasta la SE 20 del 2014 a la OPS/OMS se encuentra en el recuadro.

Desde la última actualización epidemiológica publicada en la SE 7 del 2014, Antigua y Barbuda, Haití, la República Dominicana, San Vicente y las Granadinas y Saint Kitts y Nevis confirmaron los primeros casos de transmisión autóctona. Se han detectado casos importados en Aruba, Los Estados Unidos de América y Panamá.

Es significativo que los cubanos, como es usual,nos enteramos de la presencia de una nueva epidemia; esta vez no conocida en Cuba como es la Fiebre Chikungunya, por medio de los comunicadores independiente quienes toman la iniciativa de informar; en tanto que no hay una nota de parte de las autoridades de salud en Cuba ni confirmación alguna por parte de la organización Panamericana de la Salud. Esperamos…, y seguimos preguntándonos si esta enfermedad epidémica ya se encuentra en Cuba y cuál es la magnitud del problema.
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