Women and children first! is a phrase rather infamously associated with the sinking Titanic. Although without basis in maritime law, it reflects an ethical imperative to protect those who historically are perceived as the most vulnerable in times of peril, diametrically opposed to the skewed survival-of-the-fittest posture. (Women are of course as fit or fitter than men, but that would take another editorial.)
Global commitment to protecting maternal and child health (MCH) is integral to public health, and to sustainable social and economic development as well. The World Bank estimates that the global economic burden of disease could be reduced by up to 30% with optimal implementation of half a dozen cost-effective and affordable public health and clinical services: family planning, antenatal and delivery care, immunization, integrated management of childhood illness and HIV/AIDS prevention. The UN recognized MCH as integral to its Millennium Development Goals. Then last year, the Open Working Group on Sustainable Development Goals post-2015 set specific MCH targets for the world: Goal 3 (Ensure healthy lives and promote wellbeing for all at all ages) includes ending preventable neonatal and under-5 mortality by 2030 and reducing the global maternal mortality ratio to 70 per 100,000 live births (Cuba’s was 38.9 in 2013).
Children and women of childbearing age make up almost half of Cuba’s 11.2-million population, and the country has been lauded by international organizations such as UNICEF and Save the Children for impressive MCH results. As early as 1960, the Comprehensive Program for Care of Women and Children was established. This was a forerunner to today’s National Maternal–Child Health Program, which serves as both guide and yardstick to measure what kind of job the country is doing to improve women’s and children’s health status.
The biggest test came with the 1990s, when Cuba lost 85% of its aid and trade due to the collapse of the socialist bloc. The health system, however, heeded early warning signs of increased infant mortality by taking swift measures, such as resurrecting a network of maternity homes to ensure better nutrition for at-risk mothers-to-be. As a result, indicators held the line, and some even improved over that decade.
Fast-forwarding to 2013, a Cuban woman’s lifetime risk of dying in childbirth is less than half that of women elsewhere in Latin America. The high literacy and educational levels of Cuban women doubtless contribute to this, as do universal access to health care and skilled birth attendants in nearly 100% of deliveries. Infant mortality reached an historic low of 4.2 per 1000 live births (sustained in 2014), the lowest in Latin America and the Caribbean and rivaling Canada’s—with only modest disparities among provinces. Conner Gorry’s interview with neonatologist Fernando Domínguez takes a look at how this has come to be, how it is calculated and raises the issue of further reducing the country’s maternal mortality.
The latter presents more complex challenges and is cause for dissatisfaction in Cuba: combined direct and indirect maternal mortality decreased by 44.7% between 1970 and 2013, compared to an 89.1% decrease in infant mortality over the same period. In her Viewpoint, Águila shares insights accumulated over her five-decade career about prospects for reducing maternal mortality by addressing postpartum hemorrhage, the condition responsible for about one quarter of maternal deaths worldwide and the leading direct cause of maternal mortality in Cuba.
Just days before this publication of this issue, a young woman gave birth to Cuba’s first “test-tube baby”; Cuba the one country in Latin America that provides in vitro fertilization free of charge. The site of this breakthrough was the Ramón González Coro University Maternity Hospital, where two of this issue’s authors practice, Cejas and Festary.
In eastern Cuba, Martínez’s research responds to WHO’s recommendations for population-specific reference curves for anthropometric assessment of newborns to enhance ability to identify babies at risk and improve their prognosis with more targeted care. Contreras reports on developments in screening for and treatment monitoring of hyperphenylalaninemia, an important cause of preventable intellectual impairment
Moving beyond the newborn period, Silverio examines the clinical characteristics of children with hepatic failure; Castro uses qualitative methods to explore adherence to HIV/AIDS treatment in Cuban children and adolescents; and Ferrer looks at high blood pressure in young Cubans. This last article represents a spinoff of Cuba’s participation in an 18-country WHO research initiative to identify determinants of atherosclerosis in youth, with important findings demonstrating early appearance of vascular damage—at a time when unhealthy habits may still be changed.
Other articles in this issue include research by Fernández de la Vega on lung cancer diagnostic delay and González’s Perspective on progress in developing a national dementia registry in Cuba.
For months, global attention has been riveted on Ebola in West Africa. Cuba’s response was swift, sending 256 health professionals to three stricken countries. One Cuban volunteer, Dr Félix Báez, contracted Ebola. He recovered, came home to Cuba, and has since returned to Sierra Leone where he was serving. We encourage you to read
MEDICC Review‘s exclusive interview with him and with Dr Jorge Pérez, Director of Cuba’s Pedro Kourí Tropical Medicine Institute.
As we go to press, global health experts have become cautiously hopeful about ending the Ebola epidemic, as cases still flow into Ebola treatment centers in Sierra Leone, Guinea and Liberia. They also admit that much more needs to be done together to strengthen the health systems of African and other countries to keep diseases like this at bay in the future.
And cooperation is indeed the watchword of this new year—when it comes to Ebola and to new prospects for US–Cuba cooperation in health emergencies and, in fact, across the board in medical and health research and practice. We are reminded there is much to learn from each other, and even much more to do, to make health equity and universal health coverage a reality.
We want to thank our editorial board, authors, readers and reviewers for helping to make 2014 the journal’s most ambitious and successful year yet, averaging over 35,000 online article-reads monthly. In 2015, MEDICC Review will publish two important Spanish-language resources: one in collaboration with The Lancet, a translation of its series Universal Health Coverage in Latin America, funded by The Rockefeller Foundation/ECLAC; and the Spanish of our April 2014 issue Chronic Kidney Disease Hits Agricultural Communities, thanks to support from PAHO and Queensland University, Australia.
The Editors
