Silence is Dangerous
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-
*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.
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