El trabajo en equipo: mi amigo Alfredo Espinosa
El trabajo en equipo: el caso de mi amigo Alfredo Espinosa- Cuba
Publico lo aparecido en ProCOR
[ProCOR's "Case for Prevention" profiles community-based interventions and
other
prevention initiatives around the globe to address cardiovascular risk
factors.
These case studies summarize local and national examples of cost-effective,
successful strategies promoting heart health. "Case for Prevention" is part
of
ProCOR's promotion of World Hypertension Day (Sunday, May 14) in
collaboration
with the World Hypertension League (http://www.mco.edu/org/whl/whd.html)].
Members of the ProCOR network are encouraged to share their CVD prevention
activities-email your summary to procor@healthnet.org.]
----------------
Case for Prevention: Early detection of hypertension in Cuba
The celebration of the World Hypertension Day is a valuable contribution to
global health and an opportunity to share our experiences and affirm our
commitment to hypertension prevention and control worldwide.
Pedro Ordúñez-García, MD, Alfredo Espinosa-Brito, MD, PhD, Richard Cooper,
MD,
Community-Based Hypertension Prevention and Control: Lessons learned from
CARMEN
initiative in Cienfuegos, Cuba
As is the case with many developing countries, Cardiovascular Diseases (CVD)
are
the leading cause of death in Cuba. Since the 1970s, mortality from CVD has
shown a decreasing trend, which has intensified in the last 7 to 10 years.
The
age-adjusted mortality in 2003 was 41% lower than the comparable rate
recorded
in 1970. The reduction in mortality from coronary heart disease, which
account
for nearly 74% of all heart diseases deaths, drove the overall decline in
cardiovascular mortality. In contrast, it was not until the year 2000 that
stroke, the second cause of CVD mortality, started showing a significant
decline. (1) Data from Cuba are highly accurate since registration has been
consistently high over this 30 year period and deaths attributed to ill-
defined
causes have remained very low (0.7%). All deaths are certified by a
physician.
Given the high level of education of the Cubans, the universal access to
health
care and a large public health infrastructure, Cuba presents an ideal
setting in
which to study the potential success of low-resource health systems in the
treatment and control of hypertension. Taking into account this singular
situation a demonstration site in the city of Cienfuegos was developed for
CARMEN, the PanAmerican Health Organization (PAHO) intervention program for
non-communicable diseases. (2) In a previous survey (1991-92) from the same
city
as baseline of Global Project of Cienfuegos, hypertension occurred at a high
prevalence, at least by comparative standards in the Caribbean, although
pharmacologic control was quite effective. (3)
To provide current information about prevalence, risk factor status and
treatment and control of hypertension a population-based sample of 1667
persons
ages 15-74 was recruited in Cienfuegos during 2001-02. Hypertension was
defined
as a systolic blood pressure (SBP) >= 140, a diastolic blood pressure (DBP)
>=
90, or current treatment with antihypertensive agents. Interviewers
classified
29% of participants as "black" or "mulatto" and 71% as "white". Educational
attainment was stratified at median number of school years. "Control in the
population" was defined as the percent of all hypertensives, irrespective of
treatment status, with SBP < 140 and DBP < 90. "Control in treated
patients"
was defined as the number of treated patients achieving the same goal
divided by
the number of patients on treatment. Body mass index (BMI) was calculated
as
weight/height2, in kg/m. Ninety five % confidence intervals (CI) taking
into
account the sampling design were calculated for prevalences. (4-5)
The prevalence of hypertension, weighted to the age structure of the sampled
population, was 20%. Men had significantly higher mean BP's than women and a
5%
greater prevalence of hypertension. Non-white women had higher blood
pressures
than white women (3.0/1.7, SBP/DBP) and a higher prevalence of hypertension
(24%
[95% CI = 20-28] vs. 15% [95% CI = 12-18]). Among men no differences in
blood
pressure were observed by ethnicity. No variation was observed for body
mass
index or self-reported health behaviors by ethnicity or education. High
levels
of medical attention were apparent since virtually all participants reported
having had their BP measured by a medical professional in the last 2 years.
Awareness of hypertension was high in this population and 61% of individuals
with elevated BP at the survey exam were currently receiving drug treatment.
Among all hypertensives in the population, including those previously
undiagnosed and those not currently taking medications, 40% had BP < 140/90
(95%
CI = 33-47). Among the treated patients, 65% had a SBP/DBP < 140/90.
As found in other populations, women were more likely to be aware of their
condition and to be taking medications than were men. The drugs being used
were
diuretics (37%), beta blockers (22%), calcium antagonists (14%), ACE
inhibitors
(12%), and others (15%). Availability of medications was not a significant
obstacle; 82% of participants reported little or no difficulty in finding
the
prescribed anti-hypertensive medication in the pharmacy and 91% had little
or no
difficulty buying them. (4-5)
What are the factors that could explain the success of this programme in
Cuba?
First, it is necessary to look at the quality of the data. Cienfuegos has
been
achieving a remarkable experience on this type of studies. Its first survey
was
conducted in 1991 and during more than a decade their investigators has been
created and improved well-designed surveillance tools. (6) For example, the
survey protocol used during the more recent study incorporated a
questionnaire
developed in the PAHO project that was previously recommended as standard
for
the Region of Americas, the participation rate in the clinical exam was
77.9%,
the BP measurement protocol included an extensive training with audio tapes
and
competence testing using the double-headed stethoscope, BP was measured 3
times
at the same sitting using a mercury manometer and the analyses were based on
the
mean of the last 2 readings. No terminal digit was assigned > 25% of the
values
suggesting excellent measurement technique. Height and weight were measured
in
light street clothing and an extensive questionnaire was administered by
professional interviewers. BP was measured by certified nurses and
medication
use was verified by the physician who examined the pill bottle. (4-5)
Second, health care is playing an important role.
Cuba is a country of 11,230,100 inhabitants and has a well-extended health
care
system based on a family health model. The system relies on 32,291 family
physicians who work alongside nurses in neighbourhood offices. This
exceptional
opportunity has been used by a National Health System of Cuba to promote a
very
"aggressive" policy where early detection and pharmacology treatment of
hypertension has played a very important role. Cuba launched its second
national
program for hypertension in 1998 and it was considered a model to prevent
and
control other major non-communicable diseases. (7) That program was
essentially
based on the recommendation derived from the US VI Joint National Committee
Guidelines (JNC VI). (8) Over this same period Cuba has invested resources
and
time to promote and expand those guidelines on primary health care scenario
achieving high level of training of their medical community. Despite their
economical restrictions Cuba manufactures most of the important classes of
drugs
used in the treatment of hypertension and provides them at minimal cost to
the
patient. The high rates of awareness and treatment observed in Cuba, higher
than
those of many industrialized countries and plausible due to the large health
care infrastructure, suggests both that more borderline cases are being
treated
and that the quality of care has improved, leading to better control rates.
This
latter possibility is supported by the fact that over this period
hypertension
therapy became widely available and many restrictions observed in mostly
developing countries have been removed.
Third, lifestyle factors may be having an impact. Over this period Cuban's
media has adopted a very important role and its contribution was crucial to
extend the preventive message on the context of well educated population.
Obesity occurs less frequently in Cuba than in many other countries. The
mean
BMI among adults in the Cienfuegos survey was 25 (SD = 4), and the
prevalences
of obesity (>= 30) were 14% for women, 8% for men, and 11% in the total
population. For much of the Cuban population, physical activity is enforced
by
limitations in mass transportation with a dramatic increase in people who
used a
bicycle daily. Among respondents to the Cienfuegos survey, 93% reported
engaging in moderate activity several days of the week, and 30% reported
vigorous activity. Consumption of vegetables is still low, however, with
daily
intake being reported by on 5% of respondents in a recent survey, and weekly
by
47%. On the other hand, fruits were eaten at least daily by a third of the
population, and at least weekly by 50%. Recently studies suggest a relative
low
rate of alcohol intake. (1)
Conclusions:
The technical requirements to treat and control hypertension are minimal and
the
success of the Cuban health system provides an important demonstration of
what
can be achieved in low-resource settings. Effective anti-hypertensive
therapy is
a cornerstone of CVD control, however there is a need to balance medical
approaches with primary prevention. Further progress against hypertension
will
require equally effective strategies for primary prevention; in the Cuban
context this means primarily reductions in salt intake and increases in
fruits
and vegetables. Additionally, the continued high prevalence of smoking
indicates the urgent need for a more comprehensive approach to CVD risk
reduction. Given the relative equality of living conditions, universal
medical
coverage, high levels of primary care, and provision of basic drugs Cuba
offers
a unique opportunity to answer some of the questions about program
implementation and impact of various strategies that other developing
countries
also need to address.
References:
1. Cooper RS, Ordúñez P, Iraola-Ferrer M, Bernal JL, Espinosa A.
Cardiovascular
disease and associated risk factors in Cuba: Prospects for prevention and
control. Am J Public Health. (In press).
2. Diez-Roux A, Orduñez-García P, Peruga A, Robles, SC. Networking for the
surveillance of risk factors for NCD in Latin America and the Caribbean.
Division Of Disease Prevention And Control. Program On Non-Communicable
Diseases. Pan American Health Organization. World Health Organization.
PAHO/HCP/HCN/1999.08.
3. Ordunez-Garcia P, Espinosa-Brito AD, Cooper RS, Kaufman J, Nieto FJ.
Hypertension in Cuba: Evidence of a narrow black-white difference. J Human
Hypertension 1998;12:111-116
4. Ordunez P, Bernal JLM, Espinosa-Brito A, Silva LC, Cooper RS. Ethnicity,
education and blood pressure in Cuba, Am J Epidemiol (In press).
5. Ordunez P,Bernal JLM, Pedraza D, Silva LC, Espinosa-Brito A, Cooper RS.
Hypertension treatment and control in Cienfuegos, Cuba, Hypertension, in
review.
6. Ordunez P, Silva LC, Rodriguez MP, Robles S. Prevalence estimates for
hypertension in Latin America and the Caribbean: are they useful for
surveillance? Rev Panam Salud Publica/Pan Am J Public Health
2001;10:226-231.
7. MINSAP. Programa nacional de prevención, diagnóstico, evaluación y
control de
la hipertensión arterial. La Habana. MINSAP; 1998.
8. Sixth Report of the Joint National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure, NIH, NHLBI, National High
Blood
Pressure Education Program, Bethesda, MD, 1997 (publication no. 98-4080)
_____________________________________________________________________
Contribute to ProCOR's Global Dialogue by replying to this message or
sending an email to .
ProCOR (www.procor.org) is a program of the Lown Cardiovascular
Research Foundation. ProCOR's email discussion is hosted by SATELLIFE
(www.healthnet.org), The Global Health Information Network.
Publico lo aparecido en ProCOR
[ProCOR's "Case for Prevention" profiles community-based interventions and
other
prevention initiatives around the globe to address cardiovascular risk
factors.
These case studies summarize local and national examples of cost-effective,
successful strategies promoting heart health. "Case for Prevention" is part
of
ProCOR's promotion of World Hypertension Day (Sunday, May 14) in
collaboration
with the World Hypertension League (http://www.mco.edu/org/whl/whd.html)].
Members of the ProCOR network are encouraged to share their CVD prevention
activities-email your summary to procor@healthnet.org.]
----------------
Case for Prevention: Early detection of hypertension in Cuba
The celebration of the World Hypertension Day is a valuable contribution to
global health and an opportunity to share our experiences and affirm our
commitment to hypertension prevention and control worldwide.
Pedro Ordúñez-García, MD, Alfredo Espinosa-Brito, MD, PhD, Richard Cooper,
MD,
Community-Based Hypertension Prevention and Control: Lessons learned from
CARMEN
initiative in Cienfuegos, Cuba
As is the case with many developing countries, Cardiovascular Diseases (CVD)
are
the leading cause of death in Cuba. Since the 1970s, mortality from CVD has
shown a decreasing trend, which has intensified in the last 7 to 10 years.
The
age-adjusted mortality in 2003 was 41% lower than the comparable rate
recorded
in 1970. The reduction in mortality from coronary heart disease, which
account
for nearly 74% of all heart diseases deaths, drove the overall decline in
cardiovascular mortality. In contrast, it was not until the year 2000 that
stroke, the second cause of CVD mortality, started showing a significant
decline. (1) Data from Cuba are highly accurate since registration has been
consistently high over this 30 year period and deaths attributed to ill-
defined
causes have remained very low (0.7%). All deaths are certified by a
physician.
Given the high level of education of the Cubans, the universal access to
health
care and a large public health infrastructure, Cuba presents an ideal
setting in
which to study the potential success of low-resource health systems in the
treatment and control of hypertension. Taking into account this singular
situation a demonstration site in the city of Cienfuegos was developed for
CARMEN, the PanAmerican Health Organization (PAHO) intervention program for
non-communicable diseases. (2) In a previous survey (1991-92) from the same
city
as baseline of Global Project of Cienfuegos, hypertension occurred at a high
prevalence, at least by comparative standards in the Caribbean, although
pharmacologic control was quite effective. (3)
To provide current information about prevalence, risk factor status and
treatment and control of hypertension a population-based sample of 1667
persons
ages 15-74 was recruited in Cienfuegos during 2001-02. Hypertension was
defined
as a systolic blood pressure (SBP) >= 140, a diastolic blood pressure (DBP)
>=
90, or current treatment with antihypertensive agents. Interviewers
classified
29% of participants as "black" or "mulatto" and 71% as "white". Educational
attainment was stratified at median number of school years. "Control in the
population" was defined as the percent of all hypertensives, irrespective of
treatment status, with SBP < 140 and DBP < 90. "Control in treated
patients"
was defined as the number of treated patients achieving the same goal
divided by
the number of patients on treatment. Body mass index (BMI) was calculated
as
weight/height2, in kg/m. Ninety five % confidence intervals (CI) taking
into
account the sampling design were calculated for prevalences. (4-5)
The prevalence of hypertension, weighted to the age structure of the sampled
population, was 20%. Men had significantly higher mean BP's than women and a
5%
greater prevalence of hypertension. Non-white women had higher blood
pressures
than white women (3.0/1.7, SBP/DBP) and a higher prevalence of hypertension
(24%
[95% CI = 20-28] vs. 15% [95% CI = 12-18]). Among men no differences in
blood
pressure were observed by ethnicity. No variation was observed for body
mass
index or self-reported health behaviors by ethnicity or education. High
levels
of medical attention were apparent since virtually all participants reported
having had their BP measured by a medical professional in the last 2 years.
Awareness of hypertension was high in this population and 61% of individuals
with elevated BP at the survey exam were currently receiving drug treatment.
Among all hypertensives in the population, including those previously
undiagnosed and those not currently taking medications, 40% had BP < 140/90
(95%
CI = 33-47). Among the treated patients, 65% had a SBP/DBP < 140/90.
As found in other populations, women were more likely to be aware of their
condition and to be taking medications than were men. The drugs being used
were
diuretics (37%), beta blockers (22%), calcium antagonists (14%), ACE
inhibitors
(12%), and others (15%). Availability of medications was not a significant
obstacle; 82% of participants reported little or no difficulty in finding
the
prescribed anti-hypertensive medication in the pharmacy and 91% had little
or no
difficulty buying them. (4-5)
What are the factors that could explain the success of this programme in
Cuba?
First, it is necessary to look at the quality of the data. Cienfuegos has
been
achieving a remarkable experience on this type of studies. Its first survey
was
conducted in 1991 and during more than a decade their investigators has been
created and improved well-designed surveillance tools. (6) For example, the
survey protocol used during the more recent study incorporated a
questionnaire
developed in the PAHO project that was previously recommended as standard
for
the Region of Americas, the participation rate in the clinical exam was
77.9%,
the BP measurement protocol included an extensive training with audio tapes
and
competence testing using the double-headed stethoscope, BP was measured 3
times
at the same sitting using a mercury manometer and the analyses were based on
the
mean of the last 2 readings. No terminal digit was assigned > 25% of the
values
suggesting excellent measurement technique. Height and weight were measured
in
light street clothing and an extensive questionnaire was administered by
professional interviewers. BP was measured by certified nurses and
medication
use was verified by the physician who examined the pill bottle. (4-5)
Second, health care is playing an important role.
Cuba is a country of 11,230,100 inhabitants and has a well-extended health
care
system based on a family health model. The system relies on 32,291 family
physicians who work alongside nurses in neighbourhood offices. This
exceptional
opportunity has been used by a National Health System of Cuba to promote a
very
"aggressive" policy where early detection and pharmacology treatment of
hypertension has played a very important role. Cuba launched its second
national
program for hypertension in 1998 and it was considered a model to prevent
and
control other major non-communicable diseases. (7) That program was
essentially
based on the recommendation derived from the US VI Joint National Committee
Guidelines (JNC VI). (8) Over this same period Cuba has invested resources
and
time to promote and expand those guidelines on primary health care scenario
achieving high level of training of their medical community. Despite their
economical restrictions Cuba manufactures most of the important classes of
drugs
used in the treatment of hypertension and provides them at minimal cost to
the
patient. The high rates of awareness and treatment observed in Cuba, higher
than
those of many industrialized countries and plausible due to the large health
care infrastructure, suggests both that more borderline cases are being
treated
and that the quality of care has improved, leading to better control rates.
This
latter possibility is supported by the fact that over this period
hypertension
therapy became widely available and many restrictions observed in mostly
developing countries have been removed.
Third, lifestyle factors may be having an impact. Over this period Cuban's
media has adopted a very important role and its contribution was crucial to
extend the preventive message on the context of well educated population.
Obesity occurs less frequently in Cuba than in many other countries. The
mean
BMI among adults in the Cienfuegos survey was 25 (SD = 4), and the
prevalences
of obesity (>= 30) were 14% for women, 8% for men, and 11% in the total
population. For much of the Cuban population, physical activity is enforced
by
limitations in mass transportation with a dramatic increase in people who
used a
bicycle daily. Among respondents to the Cienfuegos survey, 93% reported
engaging in moderate activity several days of the week, and 30% reported
vigorous activity. Consumption of vegetables is still low, however, with
daily
intake being reported by on 5% of respondents in a recent survey, and weekly
by
47%. On the other hand, fruits were eaten at least daily by a third of the
population, and at least weekly by 50%. Recently studies suggest a relative
low
rate of alcohol intake. (1)
Conclusions:
The technical requirements to treat and control hypertension are minimal and
the
success of the Cuban health system provides an important demonstration of
what
can be achieved in low-resource settings. Effective anti-hypertensive
therapy is
a cornerstone of CVD control, however there is a need to balance medical
approaches with primary prevention. Further progress against hypertension
will
require equally effective strategies for primary prevention; in the Cuban
context this means primarily reductions in salt intake and increases in
fruits
and vegetables. Additionally, the continued high prevalence of smoking
indicates the urgent need for a more comprehensive approach to CVD risk
reduction. Given the relative equality of living conditions, universal
medical
coverage, high levels of primary care, and provision of basic drugs Cuba
offers
a unique opportunity to answer some of the questions about program
implementation and impact of various strategies that other developing
countries
also need to address.
References:
1. Cooper RS, Ordúñez P, Iraola-Ferrer M, Bernal JL, Espinosa A.
Cardiovascular
disease and associated risk factors in Cuba: Prospects for prevention and
control. Am J Public Health. (In press).
2. Diez-Roux A, Orduñez-García P, Peruga A, Robles, SC. Networking for the
surveillance of risk factors for NCD in Latin America and the Caribbean.
Division Of Disease Prevention And Control. Program On Non-Communicable
Diseases. Pan American Health Organization. World Health Organization.
PAHO/HCP/HCN/1999.08.
3. Ordunez-Garcia P, Espinosa-Brito AD, Cooper RS, Kaufman J, Nieto FJ.
Hypertension in Cuba: Evidence of a narrow black-white difference. J Human
Hypertension 1998;12:111-116
4. Ordunez P, Bernal JLM, Espinosa-Brito A, Silva LC, Cooper RS. Ethnicity,
education and blood pressure in Cuba, Am J Epidemiol (In press).
5. Ordunez P,Bernal JLM, Pedraza D, Silva LC, Espinosa-Brito A, Cooper RS.
Hypertension treatment and control in Cienfuegos, Cuba, Hypertension, in
review.
6. Ordunez P, Silva LC, Rodriguez MP, Robles S. Prevalence estimates for
hypertension in Latin America and the Caribbean: are they useful for
surveillance? Rev Panam Salud Publica/Pan Am J Public Health
2001;10:226-231.
7. MINSAP. Programa nacional de prevención, diagnóstico, evaluación y
control de
la hipertensión arterial. La Habana. MINSAP; 1998.
8. Sixth Report of the Joint National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure, NIH, NHLBI, National High
Blood
Pressure Education Program, Bethesda, MD, 1997 (publication no. 98-4080)
_____________________________________________________________________
Contribute to ProCOR's Global Dialogue by replying to this message or
sending an email to .
ProCOR (www.procor.org) is a program of the Lown Cardiovascular
Research Foundation. ProCOR's email discussion is hosted by SATELLIFE
(www.healthnet.org), The Global Health Information Network.
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