Sherri L. Porcelain*
After a century hiatus, cholera, malaria and dengue have returned to Cuba. This is no surprise since Cuba’s deteriorated water, sewage, sanitation and housing systems all create the ideal environment for rapid disease spread. Dengue, a mosquito borne viral disease, and cholera, a bacterial infection contracted by drinking water or eating food contaminated with a strain of cholera, present threats to both the local population and tourists visiting the island.
Luis Suarez Rosas, a physician with Cuba’s National School of Medicine, accurately captures the paradox of Cuban health care today in using the term epidemiologic silence to describe Cuba’s official position on disease outbreak information. Cuba is a unique case study because of its long history of highly trained infectious disease specialists as seen in the yellow fever response in the early 1900s, and the prominence of the Pedro Kouri Tropical Medicine Institute founded in 1937. Yet, today, the policy to call dengue euphemistically as a febrile illness or cholera as a gastrointestinal illness represents an unethical national public health policy affecting individuals beyond their national borders. This choice to withhold information derails global public health goals to inform and protect travelers; it also encourages rumors and creates confusion. Suarez Rosas, using dengue as a recent example, explains how this artificial epidemiologic silence does not help patients, nor does it address the risk or the perception of the severity of the disease. Additionally, it does not respond to the culprit, the aedes aegypti mosquito, which also carries the yellow fever virus.
While both the Center for Disease Control and Prevention (CDC) and the Pan American Health Organization (PAHO) provide health alerts and identify health problems, their information often relies upon the official reporting of information. However, the Program for Monitoring Emerging Diseases (ProMED), operating under the International Society for Infectious Disease, is an internet-based information system created in 1994 with the purpose of sharing emerging and re-emerging infectious disease information. ProMED mail welcomes all sources of information, including independent journalists who have reported outbreaks long before the Cuban government forced to make an official statement. ProMED continues to share information about the re-emergence of cholera in Cuba’s Manzanillo (Granma) Province in 2012 that spread through eastern provinces, and reached the western capital of Havana.
In June 2013, an independent journalist from Hablemos Press reported approximately 30 cases of malaria in Cuba. The Cuban government claimed these cases are imported by tourists or from returning residents that traveled to an endemic area. Imported cases of malaria are not new; however, the history of Cuba’s denials of other re-emerging diseases compels one to question the veracity of the government’s official report.
Malaria expert John Beier, Professor of Public Health Sciences at the University of Miami Miller School of Medicine, states that Cuba is receptive to malaria since the mosquito has not been eliminated. It is also important to acknowledge that local pocket of transmissions can exist through imported cases from other areas in the region, such as Hispaniola where malaria is known to exist. During rainy season, and when vector population increases, the risk of transmission increases as well. Still no official government report exists.
Sharing good epidemiologic evidence in a timely fashion is a reasonable expectation for global public health cooperation to be maintained. Promoting global health security begins with greater transparency on potential health threats. These are not state secrets as proposed during the 1980s and 1990s denial of Cuba’s dengue re-emergence, along with the incarceration of health professionals who released such data.
Cuba’s policy to withhold information on infectious disease threats for the purpose of protecting their health image, or their tourism industry is unacceptable in an era where rapid and frequent transport across borders occurs. International travelers and concerned citizens everywhere must realize that mosquitoes and microbes do not require their own passport stamp for entry into the United States, and the intrepid stowaways may arrive with their presence undetected.
Based upon what we know and don’t know-
We need to:
1. Promote greater awareness about mosquito avoidance and cholera, dengue and malaria prevention for travelers to Cuba. While other countries may have higher reported cases, their risk is documented through transparency in their reporting. On June 27, 2013 the U.S. Interests Section in Havana, Cuba posted an alert message for U.S. citizens regarding road safety and traffic related deaths and injuries. This is an important health and safety message, so why not extend this to other public health issues such as dengue, malaria, and cholera?
2. Become more proactive and use Rapid Diagnostic Kits (RDK) for early identification of diseases such as dengue and malaria. This could be especially important to Travel Medicine Clinics where licensed and trained health professionals have the ability to do accurate testing and patient histories. Dr. Kunjana Mavunda, Medical Director and Tropical Disease Specialist at International Travel Clinic in South Miami, Florida supports this approach. “I’ve been looking at these rapid diagnostic kits as part of the patient care and it is important that you get a good history of the patient and identify potential exposure risks.” She indicated that Cuba’s neglected infrastructure makes it ripe for potential disease spread.
3. Generate a wider dialogue concerning Cuba’s epidemiologic silence. Notwithstanding the issues surrounding dengue, malaria and cholera, a bird flu spread remains a possibility. The 2003 Severe Acute Respiratory Syndrome (SARS) coronavirus scare originated in South China and today the Middle East Respiratory Syndrome (MERS), another coronavirus, lurks nearby. Will anyone hold Cuba accountable for failure to report early outbreaks? What about possible impact in South Florida?
Global health security depends upon the rigor of good science, the willingness of nations to uphold policies to protect both their citizens and visitors, and the timely reporting of potential health threats. A world that is forced to rely on rumors puts everyone at risk. Consequently, silence is dangerous to your health.
*Sherri Porcelain is Senior Lecturer in Global Public Health in World Affairs and a Senior Research Associate at the Institute for Cuban and Cuban-American Studies, University of Miami.