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PubMed2001

Nutritional and food protection against epidemic emerging neuropathy. Epidemiological findings in the unique disease-free urban area of Cuba.

A survey was conducted through the SECUBA (SEguridad alimentaria en CUba y Buena Alimentación) research program in Cuban healthy smokers living in Guantánamo and in Havana. The aim of the survey was to investigate biological and nutritional factors connected with the occurrence of zero epidemic neuropathy (EN) observed in Guantánamo urban area since the disease emerged in Cuba. Blood riboflavin status and carotenoid and selenium concentrations were higher in Guantánamo than in Havana smokers. Food dietary quantities of plantain banana, pepper (Capsicum spp.), bovine meat and milk products were higher in Guantánamo. Inversely, foods rich in cholesterol, especially eggs, were more consumed in Havana. Through riboflavin, carotenoid and selenium contents and specific antioxidants substances (indoleamines, capsaicin), the foods more consumed in Guantánamo could be considered as EN protective factors. Disease protective effects could be exerted via enhancement of defence mechanisms against free radical damage and related mechanisms focused on redox recycling of glutathione and local protection from carotenoids. Finally, the results of the present study should help Cuba, through a better EN control, to improve long-term food safety and define healthier dietary habits.

Adult↗

PubMed2002

Infection with human herpesvirus type 8 and human T-cell leukaemia virus type 1 among individuals participating in a case-control study in Havana City, Cuba.

Infection with human herpesvirus type 8 and with human T-cell leukaemia virus type-1 shows strong geographic variations. We conducted this study to assess prevalence and risk factors for human herpesvirus type 8 infection in Havana City, Cuba. Information and residual serum samples already collected for a hospital based case-control study were used. A total of 379 individuals (267 males and 112 females; median age=63 years) were evaluated. Antibodies to the lytic antigen of human herpesvirus type 8 were detected by using an immunofluorescence assay, while human T-cell leukaemia virus type-1 serology was performed by means of an ELISA test (alpha Biotech). Overall, 64 subjects (16.9%, 95% confidence interval: 13.1-20.0) were positive for human herpesvirus type 8 antibodies. Human herpesvirus type 8 seroprevalence significantly increased with age (odds ratio=1.9 for >/=65 vs <55 years), and was twice as frequent in blacks than in whites. No association emerged with gender, socio-economic indicators, family size, history of sexually transmitted disease, sexual behaviour. Overall, 16 persons had anti-human T-cell leukaemia virus type-1 antibodies (4.2%, 95% confidence interval: 2.2-6.4). No relationship emerged between human T-cell leukaemia virus type-1 and human herpesvirus type 8 serostatus. The study findings indicate that human herpesvirus type 8 infection is relatively common in Havana City, Cuba, suggesting that Cuba may represent an intermediate endemical area. Sexual transmission does not seem to play a major role in the spread human herpesvirus type 8 infection.

Age Factors↗

PubMed2001

Risk factors for cancer of the oral cavity and oro-pharynx in Cuba.

In terms of worldwide levels, Cuba has an intermediate incidence of cancer of the oral cavity and oro-pharynx. We studied 200 cases of cancer of the oral cavity and pharynx, of whom 57 women (median age = 64) and 200 hospital controls, frequency matched with cases by age and sex, in relation to smoking and drinking history, intake of 25 foods or food groups, indicators of oral hygiene and sexual activity, and history of sexually transmitted diseases. Odds ratios (OR) and 95% confidence intervals (CI) were obtained from unconditional multiple logistic regressions and adjusted for age, sex, area of residence, education, and smoking and drinking habits. In the multivariate model, high educational level and white-collar occupation, but not white race, were associated with halving of oral cancer risk. Smoking > or =30 cigarettes per day showed an OR of 20.8 (95% CI: 8.9-48.3), similar to smoking > or =4 cigars daily (OR = 20.5). Drinking > or = 70 alcoholic drinks per week showed an OR of 5.7 (95% CI: 1.8-18.5). Hard liquors were by far the largest source of alcohol. Increased risk was associated with the highest tertile of intake for maize (OR = 1.9), meat (OR = 2.2) and ham and salami (OR = 2.0), whereas high fruit intake was associated with significantly decreased risk (OR = 0.4). Among indicators of dental care, number of missing teeth and poor general oral condition at oral inspection showed ORs of 2.7 and 2.6, respectively. Number of sexual partners, marriages or contacts with prostitutes, practice of oral sex and history of various sexually transmitted diseases, including genital warts, were not associated with oral cancer risk. 82% of oral cancer cases in Cuba were attributable to tobacco smoking, 19% to smoking cigars or pipe only. The fractions attributable to alcohol drinking (7%) and low fruit intake (11%) were more modest. Thus, decreases in cigarette and cigar smoking are at present the key to oral cancer prevention in Cuba.

Adult↗

PubMed2006

Chronic kidney disease in Cuba: epidemiological studies, integral medical care, and strategies for prevention.

The experience of the Republic of Cuba regarding epidemiological studies, integral medical care, and strategies for the prevention of chronic kidney disease is summarized in this report. Cuba has a National Program for Chronic Renal Disease, Dialysis, and Renal Transplantation. There is a national nephrology net, integrated by the Institute of Nephrology as the coordinator center, that has 47 nephrology services with a hemodialysis unit (24 of them with peritoneal dialysis unit), 9 transplantation centers, 33 organ procurement hospitals, and 5 histocompatibility laboratories. In 2004, the incidence rate in dialysis patients was 111 pmp, and the prevalence rate was 149 pmp, demonstrating an increasing mean of 17.0% and 10.0% per year, respectively. Renal transplantation rate was 16.6 pmp. The detection, registration, and follow-up of patients with chronic kidney disease (serum creatinine > or =1.5 mg/dL or glomerular filtration rate <60 mL/min) by family doctors was 9,761 patients, 0.87 patients per 1,000 inhabitants. In the 1980s, three population-based screening studies were performed to define the burden of chronic renal failure in different regions of Cuba. The prevalence rate was 1.1, 3.3, and 3.5 per 1,000 inhabitants, respectively. At present, another three population-based screening studies are ongoing in order to detect the chronic kidney disease in earliest stages. The continuing medical education activities have been very useful in raising the awareness of medical doctors and the basic health staff about the threats posed by and the strategies to prevent, diagnose, and treat chronic kidney disease.

Cuba↗

PubMed2001

Isolates from four different HIV type 1 clades circulating in Cuba identified by DNA sequence of the C2-V3 region.

According to the epidemiology of human immunodeficiency virus infection in Cuba, the main sources of infection have been persons coming from foreign countries, mainly from Africa, and individuals who have had sexual contacts with foreigners in Cuba. However, the first Cuban HIV-1 isolates sequenced have been all classified as subtype B. In this note we report the sequence of the gp120 C2/V3 region from 11 HIV-1 isolates from Cuban patients. DNA was isolated either directly from blood PBMC or from primary isolates, PCR amplified and sequenced. Six isolates were classified as subtype B and three of them had the atypical sequences GRGR, GWGR, and TPGR on the tip of the V3 loop. Besides, two other sequences were classified as subtype A, two as subtype H, and one as subtype C. These results confirm that although subtype B seems to be predominant, HIV-1 isolates from various subtypes do circulate in Cuba.

Amino Acid Sequence↗

PubMed2004

What the Cuban context provides health researchers: the feasibility of a longitudinal multi-method study of the impact of housing improvements on health in Havana, Cuba.

BACKGROUND: From extensive participatory research in inner city communities in Central Havana, Cuba, we found housing to be the largest perceived source of health risk. The objective of this study, therefore, was to ascertain the feasibility of conducting a multi-method longitudinal evaluation of the impact of housing improvements on health. METHODS: Meetings with community and governmental stakeholders were held; housing policy documents were reviewed; key informants were interviewed; decisions were made by a collaborative interdisciplinary team regarding measurement instruments for health as well as housing quality; training was conducted for use of new measurement tools; and a 3 month multi-method trial with repeated measures was conducted on individuals in good housing and poor housing in the inner city of Central Havana. Questionnaires were administered at monthly intervals for 3 months to 25 adults living in good housing and 25 in poor housing. RESULTS: Cuba's housing policies made it easy to identify a suitable cohort and control group for possible longitudinal study. Consent to participate was enthusiastically obtained, and no difficulties were encountered in collecting or analysing the data. Housing quality measurements were conducted using validated instruments with minimal difficulties. There was strong community involvement and support for a comprehensive longitudinal study. CONCLUSION: Cuba, although a poor country, has the necessary infrastructural support and capacity to make it an excellent site for health and housing intervention studies.

Adult↗

PubMed2005

Identification of a novel HIV-1 complex circulating recombinant form (CRF18_cpx) of Central African origin in Cuba.

BACKGROUND: Analysis of partial pol and env sequences have indicated a high diversity of HIV-1 genetic forms in Cuba, including two potential novel circulating recombinant forms (CRF): U/H and D/A. OBJECTIVES: To determine whether U/H recombinant viruses from Cuba, detected in 7% of samples, represent a novel HIV-1 CRF, and to identify non-Cuban viruses related to this recombinant form. METHODS: Near full-length genome amplification was carried out by nested polymerase chain reaction in four overlapping DNA segments of two epidemiologically unlinked viruses in uncultured peripheral blood mononuclear cells. The sequences were analysed phylogenetically. Recombinant structures and phylogenetic relationships were analysed by bootscanning and by maximum likelihood. Searches for related viruses in databases were initially based on sequence homology and sharing of signature nucleotides. RESULTS: Both Cuban viruses clustered uniformly in bootscans all along the genome with each other and with a virus from Cameroon, CM53379, indicating that all three represent the same recombinant form. Their genome comprised multiple segments clustering with subtypes A1, F, G, H and K, as well as segments failing to cluster with recognized subtypes. The newly defined CRF, designated CRF18_cpx, was phylogenetically related in partial segments to CRF13_cpx, CRF04_cpx and 36 additional viruses, most of them from Central Africa. One of the viruses from Cameroon, sequenced in the near full-length genome, was a CRF18_cpx/subtype G secondary recombinant. CONCLUSIONS: A novel HIV-1 complex circulating recombinant form (CRF18_cpx) has been identified that is circulating in Cuba and Central Africa.

Africa, Central↗

PubMed2005

Identification of a novel HIV-1 circulating ADG intersubtype recombinant form (CRF19_cpx) in Cuba.

Circulating recombinant forms (CRFs) represent a substantial proportion of HIV-1 isolates in the global pandemic. Characterization of HIV-1 genetic forms, including CRFs, may be relevant to studies on molecular epidemiology, recombination, superinfection, vaccine development, and antiretroviral therapy. This study analyzes near complete genomes of 4 epidemiologically unlinked viruses from Cuba, originally characterized as D/A intersubtype recombinants in pol and env segments. The genomes of 3 viruses exhibited virtually coincident mosaic structures, with multiple segments of subtypes A, D, and G and uniform phylogenetic clustering with each other along the genome. These results allow us to define a new CRF (CRF19_cpx). The 4th analyzed Cuban virus was recombinant between CRF19_cpx and CRF18_cpx (which also circulates in Cuba). CRF19_cpx exhibited homology to an AG intersubtype recombinant virus from Cameroon (CM53392) along approximately 5 kb and clustered with a subtype D virus from Gabon (G109) in gag. Four other viruses from central or west Africa were also phylogenetically related to CRF19_cpx in env fragments. These results allow us to define CRF19_cpx as a second novel CRF of African origin circulating in Cuba, to identify putative representative viruses of its parental strains, and to characterize a unique CRF18/CRF19 recombinant virus.

Adult↗

PubMed2000

Towards elimination of tuberculosis in a low income country: the experience of Cuba, 1962-97.

BACKGROUND: This study describes the epidemiological trends of tuberculosis in Cuba and the performance of the tuberculosis control programme. The circumstances that caused an increase in the incidence of new cases of tuberculosis between 1991 and 1994 had been analysed and were corrected in 1995-7. METHODS: A descriptive study of the incidence rates of new cases of tuberculosis notified from 1962 to 1997 was made, with special emphasis on the total change between 1965 and 1991 and the increase thereafter. RESULTS: The case notification rate of 14.7 per 100 000 in 1994 was almost three times the rate found in 1991 (4.8 per 100 000) and reversed the mean annual decrease of 5% observed since 1965. This increase was almost twofold in the rate of smear positive new cases (4.4 per 100 000 in 1991 and 8.3 in 1994). From 1971 onwards the programme had achieved a cure rate of 90% throughout the country with only 2% absconding by applying directly observed treatment. The main factors associated with the increasing trends were: (1) a probable underdetection of cases for the 1988-92 period that generated contagious sources in the community; (2) improved case finding from 1993 onwards and the introduction of an expanded case definition in 1994; (3) a considerable increase in the diagnostic delay from initial medical consultation to beginning of antituberculosis treatment (56.9 days in 1993); and (4) operational changes in the tuberculosis control programme due to the economic crisis in Cuba. In 1995, 1996 and 1997 it has been possible to reverse this trend, achieving rates of 14.1, 13.5, and 12.2 per 100 000, respectively (7. 6, 7.6, and 6.9 for smear positive cases) as a result of effective intervention correcting the problems identified. Reducing the diagnostic delay attributable to shortcomings in the health care system and the study of contacts were of particular importance for re-establishing the tuberculosis programme as a priority. CONCLUSIONS: Cuba represents a good example of how it is possible to fight against tuberculosis effectively, even in a low income country, by applying control strategies advocated by the World Health Organisation and the International Union Against Tuberculosis and Lung Disease and by giving adequate support to the programme through political commitment.

Cuba↗

PubMed1998

Epidemic neuropathy in Cuba: a public health problem related to the Cuban Democracy Act of the United States.

In 1992, the USA embargo on Cuba was tightened through the passage of the Cuban Democracy Act (CDA) that explicitly restricts food and medical supplies. The embargo has contributed to cause a number of public health problems in Cuba including: (1) an epidemic of more than 50,000 cases of optic and peripheral neuropathies in 1992-1993, resulting from dietary deficiency; (2) an epidemic of esophageal stenoses in toddlers who inadvertently drank liquid lye as a result of a soap shortage for which liquid lye was substituted; (3) an outbreak of Guillain-Barré syndrome in Havana, in June and July 1994, resulting from water contamination due to lack of chemicals for water treatment to eliminate Campylobacter sp.; (4) outbreaks of self-inflicted disease and injuries caused by rioting among Cubans detained at the US Naval base at Guantánamo Bay, and (5) a decline in medical practice standards and public health indicators in Cuba resulting from the enactment of the CDA, documented by the American Public Health Association in 1993 and confirmed in March 1997 by the American Association for World Health. Despite this evidence, the Cuban embargo remains a politically sensitive subject in the USA, resistant to public health concerns, as evidenced by the recent passage of the Helms-Burton Act. The public health effects of the CDA need to be reviewed with possible revocation or at least modification.

Adolescent↗

PubMed1990

Epidemiological study of Hodgkin's disease in Cuba and Sweden.

In this register study the epidemiologic features of Hodgkin's disease (HD) in Cuba and Sweden during 1964-1981 are compared. HD in the adult (greater than or equal to 15 years of age) is more common in Sweden than in Cuba (age-standardized incidence rate 3.6 X 10(5) vs. 3.1 X 10(5) but for childhood HD the opposite is true (2.1 X 10(5) vs. 3.0 X 10(5). In both countries a male predominance is found. A decrease in the incidence of HD is noted only in the Swedish population after 1973. The study reveals a stable bimodal age incidence pattern in Sweden but a shift from a linear increasing to a bimodal incidence pattern in Cuba, which parallels the Cuban development from an agricultural to an industrialized country.

Adolescent↗

PubMed1994

Epidemic neuropathy in Cuba: a plea to end the United States economic embargo on a humanitarian basis.

During 1992-1993, an epidemic of neurologic disease in Cuba affected 50,862 patients with optic neuropathy, sensorineural deafness, predominantly sensory peripheral neuropathy, and dorsolateral myelopathy. The clinical syndromes were identical to those of prisoners of war subjected to nutritional restriction in tropical prison camps during World War II (Strachan's disease). A dietary deficiency of group B vitamins and sulfur-containing amino acids appears to have been the primary cause of the epidemic. This was a consequence of economic and political events in Cuba linked to the collapse of the Soviet Union and socialist countries. The recently toughened 30-year-old US economic embargo on Cuba contributed to these problems and hampered the investigation, treatment, and prevention of the epidemic. A plea is made to the neurologic community to request the lifting of the trade blockade on a humanitarian basis.

Altruism↗

PubMedDate not supplied

[The transfusion medicine program in Cuba].

Cuba's Transfusion Medicine Program (TMP) is a subsystem of the country's National Health System. The TMP's objective is to ensure hemotherapy with blood that is safe and sufficient for all the individuals who need it. The TMP subsystem is made up of the National Commission on Transfusion Medicine, the Institute of Hematology and Immunology, 37 clinical services, 44 blood banks, 120 collection centers, 19 mobile units, and 37 blood certification laboratories. Additional facilities include a laboratory for plasma separation, a laboratory that produces leukocyte interferon and transfer factor, and two laboratories that produce reagents for blood classification and blood diagnosis symptoms. In Cuba, blood donation is voluntary. Since 1997 approximately 5% of the population per year has donated blood, thus meeting the goal recommended by the Pan American Health Organization of one voluntary blood donation annually for every 20 persons. During 2002, 563,204 blood donations were received, and there were 445,898 transfusions of blood or blood components. All donations are individually screened for HIV 1 and 2, hepatitis B, hepatitis C, and syphilis, thus meeting the country's current regulations. In 2002 these screening measures led to discarding, respectively, 0.12%, 0.60%, 0.71%, and 1.8% of the blood donations. Although the prevalence of human T-cell lymphotropic virus I and II in Cuba is very low, this test will soon be added to the screening process.

Blood Banks↗

PubMed2004

[Community participation in the control of Aedes aegypti: opinions of the population in one section of Havana, Cuba].

OBJECTIVE: To analyze opinions on community participation held by residents of one section of the city of Havana, Cuba, in order to identify key criteria to use in preparing a participatory strategy for controlling the Aedes aegypti mosquito. METHODS: The study was conducted from September to October 1999 in Playa, one of the 15 municipios (districts) that make up the city of Havana, Cuba. In the first phase of the study, interviews were carried out with key informants, including health brigade members and sanitation activists, who had lived in Playa for more than five years. The key informants were selected randomly from the nine health areas that the Playa municipio has. Qualitative content analysis was used to identify terms, common expressions, and key concepts related to community participation in the area. In the study's second phase a questionnaire using a Likert scale was prepared for application with a population sample from Playa. Based on the answers from the respondents, a point score with a confidence interval was calculated for each of the 30 statements on the questionnaire. The point scores for those statements were used to identify the population's most relevant criteria, that is, the statements producing the strongest agreement and the ones producing the strongest disagreement. RESULTS: In the first phase, from the interviews with key informants, the three most important variables to explore were identified as: (1) community participation in environmental cleanup, (2) the role and image of community leaders and of community organizations, and (3) community participation, in a general sense, in solving any problem in the community. In the second phase, the population survey indicated that the members of the community recognized the usefulness of community participation in solving local problems, especially for controlling A. aegypti. Among the statements on the questionnaire that had the highest levels of agreement were ones dealing with the value of working together as a team, the knowledge that local authorities had of community problems, and recognition of the obligation that citizens have to take part in developing the community. The statements that had the lowest level of agreement had to do with the need to reward-with more than just words of thanks-residents who regularly serve the community and with the view that the majority of community leaders were more concerned with their personal well-being than with the problems of the community. CONCLUSIONS: The opinions on community participation identified among the population in Playa served as the basis for designing new strategies for controlling A. aegypti. The methodology utilized in this study could be used to plan local participatory processes, both in Cuba and in other countries, and could be applied to other problems whose solution requires community participation.

Aedes↗

PubMed2004

[Efficacy and safety of a vaccine against human leptospirosis in Cuba].

OBJECTIVES: To evaluate the efficacy of vax-SPIRAL, a Cuban vaccine against leptospirosis, and to provide additional information concerning the safety of this vaccine (which was developed by Cuba's Finlay Institute). METHODS: This phase III efficacy trial of vax-SPIRAL was controlled, randomized, and double blind. The control vaccine used for the trial was Heberbiovac-HB (Heber Biotec, Cuba), a recombinant hepatitis B vaccine. The randomization unit for allocating persons to the study group or the control group were 523 family physician offices in the selected municipalities. The study covered the entire population of males and females from 20 to 64 years old who voluntarily agreed to participate, from the municipalities of Ranchuelo, Quemado, Santo Domingo, Encrucijada, Corralillo, Cifuentes, and Camajuaní, which are in the province of Villa Clara, in the central region of Cuba. The vaccinations were given in the physicians' offices between February and July 1998, with an interval of 6 weeks between the two doses. The follow-up period was 12 months. A case was considered positive if a person who had received the two doses of the vaccine became ill with leptospirosis more than 21 days after receiving the second dose, with the diagnosis confirmed through serological and microbiological methods. We calculated the efficacy of the vaccine and the relative risk of becoming ill with leptospirosis after the vaccination. For the safety study, two persons were chosen at random from among the individuals vaccinated at the office of each physician participating in the study. Follow-up of local and systemic adverse reactions was carried out by the family physicians during the seven days after the application of each dose. The level of statistical significance was set at 0.05. RESULTS: A total of 101 832 persons were vaccinated, with 50 354 of them (49.4%) receiving the leptospirosis vaccine and 51 478 of them (50.6%) receiving the control vaccine. The efficacy of the vax-SPIRAL vaccine was 78.1% (95% confidence interval (CI): 59.2% to 88.3%), and the relative risk of becoming ill with leptospirosis after receiving the leptospirosis vaccine was 0.22 (95% CI: 0.12 to 0.41). General discomfort was the most frequent systemic adverse reaction, and mild spontaneous pain at the injection site was the most frequent local effect. The local and systemic adverse reactions were both more frequent in the study group than in the control group (P = 0.003). There were no serious adverse events. CONCLUSION: The vax-SPIRAL vaccine proved to be safe and efficacious for leptospirosis control. The vaccine is recommended for use in preventing this disease among groups at risk of contracting it.

Adult↗

PubMed1991

Cuba's response to the HIV epidemic.

BACKGROUND: Cuba's response to the human immunodeficiency virus (HIV) epidemic has been to conduct mass testing of the population to ascertain seroprevalence, to enforce mandatory relative quarantine of persons testing positive, and to implement educational interventions using media and school-based programs. METHODS: Interview with the Vice-Minister of Health and review of available data. RESULTS: Reports to date show a very low seroprevalence rate without evidence of a widespread epidemic. Sexual contact with foreign-born persons is the primary risk factor. Possible advantages of Cuba's policy include rapid reduction in the risk of HIV transmission by infected blood products, an opportunity for focused education and secondary prevention, and limitation of new infections. Possible disadvantages include the restriction of individual freedom in those who are not guilty of any illegal act, quarantine of persons with false positive HIV tests, and ongoing transmission because of the incomplete nature of the quarantine. The policy is expensive and may displace other public health priorities. The content of the media-based educational interventions has emphasized rational medical information in unimaginative formats with a limited focus on prevention. CONCLUSIONS: The issue of personal responsibility for behavioral change versus government imposed regulations is at the core of Cuba's HIV policy. The quarantine policy may paradoxically permit most Cubans to feel that they are personally invulnerable to the HIV epidemic.

Acquired Immunodeficiency Syndrome↗

PubMed1997

The impact of the economic crisis and the US embargo on health in Cuba.

OBJECTIVES: This paper examines the combined effects of a severe economic decline since 1989 and a tightening of the US embargo in 1992 on health and health care in Cuba. METHODS: Data from surveillance systems for nutrition, reportable diseases, and hospital diagnoses were reviewed. These sources were supplemented with utilization data from the national health system and interviews with health leaders. RESULTS: Changes in Cuba include declining nutritional levels, rising rates of infectious diseases and violent death, and a deteriorating public health infrastructure. But despite these threats, mortality levels for children and women remain low. Instead, much of the health impact of the economic decline of Cuba has fallen on adult men and the elderly. CONCLUSIONS: To be consistent with international humanitarian law, embargoes must not impede access to essential humanitarian goods. Yet this embargo has raised the cost of medical supplies and food Rationing, universal access to primary health services, a highly educated population, and preferential access to scarce goods for women and children help protect most Cubans from what otherwise might have been a health disaster.

Adolescent↗

PubMed1987

The prevention of health risks in Cuba.

Cuba still has a double burden of health risks. It must contend with some risks to health that persist in underdeveloped rural areas, and it must also deal with the risk factors associated with modern, urban living conditions. The economic and social changes fostered in the postrevolutionary period have reduced the relative importance of the first set of factors, but the changes have also introduced or intensified a myriad of factors derived from their own successes. In this article, the risk factors of greatest concern in contemporary Cuba are described, and the strategies adopted to combat these risk factors, together with the ways in which such strategies are shaped by Cuba's social and economic development are discussed.

Chronic Disease↗