INTRODUCCIÓN Durante los últimos 40 años, se ha reportado una alta prevalencia de tabaquismo en Cuba, que incluye la ciudad de Cienfuegos en la parte central de la isla.

OBJETIVO Determinar la prevalencia de tabaquismo y los potenciales factores de riesgo asociados en la ciudad de Cienfuegos durante 2010-2011.

MÉTODOS Se realizó un estudio descriptivo de corte transversal en la ciudad de Cienfuegos, en el contexto de CARMEN (Conjunto de Acciones para Reducir Multifactorialmente las Enfermedades no Transmisibles), una iniciativa de varios países de la OPS para un enfoque multidimensional de las enfermedades crónicas no transmisibles. Los participantes, 2 193 (con edades entre 15-74 años), se seleccionaron al azar a través de un complejo muestreo probabilístico en tres etapas. Las variables examinadas en relación con el tabaquismo incluyeron la edad, el sexo, el color de la piel, el estado civil y el nivel de educación.

RESULTADOS Aproximadamente el 25% de los encuestados eran fumadores (el 30.3% de los hombres y el 21.0% de las mujeres). Para los hombres, la mayor prevalencia estuvo en los grupos de 25-34 y 55-64 años; para las mujeres, en el grupo de 45-54 años. Con respecto al color de la piel, las tasas de tabaquismo fueron mayores entre los negros y los mestizos (29.5%); y en relación con el estado civil, entre los que estaban separados, viudos o divorciados (30.0%). La prevalencia de tabaquismo disminuía al aumentar el nivel educacional; de acuerdo con esa tendencia, el grupo con educación universitaria tuvo la menor prevalencia (16.2%).

CONCLUSIONES Aunque uno de cada cuatro residentes en Cienfuegos con edades ≥15 años fumaba en 2010-2011, la prevalencia allí fue menor que en encuestas anteriores. Las diferencias observadas por: edad, sexo, color de la piel, estado civil y nivel educacional pueden ser útiles para la planificación de las acciones futuras de prevención y control del tabaquismo.

PALABRAS CLAVE Tabaco, tabaquismo, prevalencia, encuestas de salud, vigilancia de factores de riesgo, Cuba

Este trabajo contextualiza la epidemia de enfermedad renal crónica y la carga de enfermedad relacionada que afecta a las comunidades agrícolas de la América Central. Se analizan las dos hipótesis principales (estrés por calor y agroquímicos), se llama la atención acerca de las consecuencias del razonamiento dicotómico concerniente a la causalidad, y se precave sobre el potencial conflicto de intereses y su papel en “la construcción de la duda”. Se describen algunos errores metodológicos que comprometen los resultados de estudios anteriores y se advierte acerca del peligro de dilatar las acciones de la salud pública hasta que se alcance una comprensión concluyente en relación con las causas de la epidemia y de los mecanismos subyacentes. Se fundamenta la necesidad de un enfoque integral de los hechos históricos, epidemiológicos y sociales de la epidemia, para valorar críticamente los estudios existentes e incrementar el rigor denuevas investigaciones.

PALABRAS CLAVE Epidemiología, salud pública, enfermedad renal crónica, causalidad, epidemia, agricultura, medio ambiente, agroquímicos, pesticidas, estrés por calor, determinantes sociales de salud, América Central

A review was conducted of screening strategies for detecting the main cancer sites for which screening has been recommended, assessing WHO and other international organizations’ positions, as well as the requirements of Cuba’s cancer control strategy. Universally, screening is recommended for cervical, breast and colorectal cancer, all included in the Cuban strategy. Additionally, in Cuba, PSA testing is indicated for men considered at risk (aged >45 years with family history) and those aged >50 years who request it; annual oral exams and teaching of oral self-examination are recommended for the entire population; and for adults aged >35 years, active annual oral cancer case finding. Screening for skin cancer is performed by physical examination of individuals at risk. To maximize benefits of early cancer detection, greater coverage is needed as well as studies of how well screening is performing under current Cuban conditions.

KEYWORDS Cancer, early detection, screening, secondary prevention, breast cancer, cervical cancer, colorectal cancer, skin cancer, oral cancer, Cuba

INTRODUCTION Over the last 40 years, high smoking prevalence has been reported throughout Cuba, including in Cienfuegos city in the central part of the island.

OBJECTIVES Determine smoking prevalence and potential associated risk factors in Cienfuegos city for 2010–2011.

METHODS A descriptive cross-sectional study was conducted in Cienfuegos city in the context of CARMEN (Collaborative Action for Risk Factor Prevention & Effective Management of Non-communicable Diseases), a PAHO multi-country initiative for a multidimensional approach to chronic non-communicable diseases. Participants totaled 2193 (aged 15–74 years), randomly selected through complex probabilistic three-stage sampling. Variables examined in relation to smoking included age, sex, skin color, civil status and educational level.

RESULTS Approximately 25% of those surveyed were smokers (30.3% of men and 21.0% of women). For men, prevalence was highest in the groups aged 25–34 and 55–64 years; for women, in the group aged 45–54 years. Concerning skin color, smoking rates were higher among black and mestizo persons (29.5%); and concerning civil status, higher among those who were separated, widowed or divorced (30.0%). Smoking prevalence fell with higher educational level; in keeping with that trend, the university-educated group had the lowest prevalence (16.2%).

CONCLUSIONS Although one in four Cienfuegos residents aged ≥15 years smoked in 2010–2011, prevalence there is lower than in previous surveys. Knowledge of differences observed in age, sex, skin color, civil status and educational level can be useful for planning future smoking prevention and control actions.

KEYWORDS Tobacco, smoking, prevalence, health surveys, risk factor surveillance, Cuba

This paper contextualizes the chronic kidney disease epidemic and related burden of disease affecting Central American farming communities. It summarizes the two main causal hypotheses (heat stress and agrochemicals), draws attention to the consequences of dichotomous reasoning concerning causality, and warns of potential conflicts of interest and their role in “manufacturing doubt.” It describes some methodological errors that compromise past study findings and cautions against delaying public health actions until a conclusive understanding is reached about the epidemic’s causes and underlying mechanisms. It makes the case for a comprehensive approach to the historical, social and epidemiological facts of the epidemic, for critically assessing existing studies and for enhanced rigor in new research.

KEYWORDS Epidemiology, public health, chronic kidney disease, causality, epidemic, agriculture, environment, agrochemicals, pesticides, heat stress, social determinants of health, Central America

One of the most common shortcomings in non-communicable disease risk factor surveillance, especially in prevalence studies, is sampling procedures, which can and do compromise accuracy and reliability of derived estimates. Moreover, sampling consumes significant time and resources. Since the early 1990s, risk factor surveys in Cienfuegos province, Cuba have paid particular attention to careful sampling methods. The new survey conducted in 2011 was not only statistically rigorous but introduced an innovative, more efficient method. This article provides a detailed description of the sample design employed to optimize resource use without compromising selection rigor.

KEYWORDS Sampling, descriptive studies, risk factors, non-communicable diseases, hypertension, Cuba

Between 1994 and 2009, the Dr Gustavo Aldereguía University Hospital of Cienfuegos, Cuba implemented a series of interventions that reduced acute myocardial infarction case fatality rate from 47% to 15%. These interventions were part of an institutional plan for myocardial infarction included in the hospital’s overall quality assurance strategy. Outcomes resulted primarily from organizational changes (from upgrading of the hospital emergency department and provincial emergency system to creation of a comprehensive coronary care unit and a chest pain center); optimizing use of effective drugs (streptokinase, aspirin, ACE inhibitors and beta blockers); adherence to clinical practice guidelines; and continual and participatory evaluation and adjustment.

KEYWORDS Acute myocardial infarction, hospital mortality, case fatality rate, health care quality assurance, management quality circles, institutional practice, guideline adherence, clinical practice guideline

Population aging, smoking, unhealthy diet and physical inactivity, in the context of globalization and unregulated urbanization, explain the high prevalences of hypertension, hypercholesterolemia and diabetes in the Americas, making cardiovascular diseases the main cause of death. Moreover, cardiovascular diseases and their risk factors disproportionately affect the poorest people, obstructing antipoverty efforts and further deepening health and other inequities. The global crisis of chronic non-communicable diseases has reached such proportions that the UN General Assembly called a high-level meeting in September 2011 to address the issue as one of human development, aiming to stimulate political commitment to a concerted global effort to stem the pandemic. In reference to the Americas, this article reviews the burden of cardiovascular diseases and describes priorities for strategies and action in the region and their relation to the results of the UN meeting.

Article in press reprinted from Health Policy (2010), doi:10.1016/j.healthpol.2010.01.005 with permission from Elsevier. © Elsevier Ireland Ltd.

ABSTRACT
Cuba’s public health system is well known for its integrated first line services based on family medicine. Less publicized is the country’s experience in public hospital management. After a harsh economic crisis in the first half of the 1990s had brought the Cienfuegos hospital near to collapse, from 1996 onwards the hospital management team took advantage of the incipient economic recovery to launch an ambitious recovery process. This article reconstructs this endeavor, based on annual hospital reports, scientific publications by the hospital staff, and interviews with key decision-makers.

First the endless waiting list for elective surgery was tackled through a more efficient use of the surgery department, and an increase of ambulatory surgery. Next, overall hospital efficiency was improved in the aim to drastically reduce the average length of stay, reaching a decrease from an average stay of 12 days to a little more than 6 days in 1999. Also the emergency department was reorganized, setting up a triage system based on a color code, linked to specific emergency protocols. Attention for improving the clinical efficiency for AMI and stroke coincided with a drop in their intrahospital lethality.

Clinical guidelines for the most important diagnoses were collectively developed, adapting international evidence to the local setting. An individual and collective performance evaluation system was elaborated in a participatory way, and further evolved into a ‘total quality management’ process.

This experience of Cienfuegos hospital provides an interesting example on how a public hospital – embedded in a well developed national public health system – can be effective and efficient, even in circumstances of limited resources.

Keywords Hospital management, public health system, health services organization, strategic planning, Cuba