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Pediatric Gastroenterology in Cuba

Castaneda, Carlos M.D.

Section Editor(s): Baker, Robert D. Jr. M.D., Ph.D.; Rosenthal, Philip M.D.; Sherman, Philip M. M.D., F.R.C.P.C.; Finkel, Yigael M.D., Ph.D.

Journal of Pediatric Gastroenterology and Nutrition: November 2001 - Volume 33 - Issue 5 - p 525-526
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Chief, Section of Pediatric Gastroenterology, National Institute of Gastroenterology, Professor of Pediatric Gastroenterology, Department of Pediatrics, School of Medicine, University of Havana, Havana, Cuba, casta@infomed.sld.cu

Pediatric Gastroenterology emerged in Cuba in 1972 when the specialty's first service was created at Havana's National Institute of Gastroenterology. Its creation occurred in the context of intense interest and planning for improving the country's public health, which characterized those years. There was an identified need to take a leap forward in specialized care of children's digestive diseases; however, since 1959, the country already had the antecedent of carrying out laparoscopies on children, even on babies, by adult gastroenterologist Professor Raimundo Llanio, who was the principal promoter of pediatric gastroenterology.

The initial pediatric gastroenterology service was led by an experienced professor of pediatrics (the late Eladio Blanco-Rabasa), with only a clinical base and a group of three young physicians who carried out their residence at this newly established Service of Pediatric Gastroenterology. Shortly afterward, these three doctors received scholarships to study pediatric gastroenterology in France with Daniel Alagille, in England with Charlotte Anderson, and in Mexico with Leopoldo Vega. This intensive training, carried out in that time, was decisive for the development of the specialty in Cuba.

Residency in pediatric gastroenterology now includes 3 years of training to achieve expertise in clinical practice, diagnostic and therapeutic endoscopy, and other techniques, such as peroral intestinal biopsy, percutaneous hepatic biopsy, and manometry. Our training program is certified by Havana's School of Medicine. Pediatricians may also receive training for blocks of 18 months, focusing mainly on endoscopy.

Cuba is a country with more than 11 million inhabitants, with an under-15-years-of-age population of almost 2.5 million. Health and education are prioritized sectors. According to UNICEF, Cuba is among the top 30 countries in the world with the lowest infant mortality rate. In 1999 and 2000, the country's infant mortality rate was 6.5 and 7.2 per 1,000 live births; the mortality rate among children younger than 5 years of age was 11.1 per 1,000 live births, with a 98.9% survival rate at 5 years of age in 2000. Life expectancy is 74 years. The National Health System is free, and the population has access to it. Pediatric gastroenterology care is given to all children and adolescents in the country, including any type of examination or exploration.

Currently, the country has a national network of pediatric gastroenterology services in 19 children's hospitals, with more than 35 specialists, in addition to the original service founded in 1972, which still serves as the referral center for the specialty and where physicians from Latin America are trained. Many of the pediatric gastroenterologists are also professors at the School of Medicine and others are also researchers, carrying out for the past 20 years, applied clinical studies. Furthermore, many Cuban pediatric gastroenterologists have participated in medical cooperation programs in several African countries. This kind of work has also been very fruitful for both sides, particularly for the Cubans because they have lived through the African reality and have acquired experience in digestive diseases that are nonexistent in Cuba.

Some of the most important achievements of pediatric gastroenterology in Cuba are 1) the generalization throughout the country of endoscopy as a diagnostic and therapeutic method; 2) the demonstration of celiac disease in a Caribbean country, with a high incidence among white and black persons; 3) the application since the 1980s of recombinant interferon produced in the Genetic Engineering and Biotechnology Center (CIGB) for chronic hepatitis B and, subsequently, for chronic hepatitis C (1); 4) in 1989, Havana was the venue of the 8th Meeting of the Latin American Society of Pediatric Gastroenterology and Nutrition; 5) the National Vaccination Program against Hepatitis B (2), carried out since 1992, with a national recombinant vaccine having a high immunologic level and also produced in the Cuban CIGB. This program is universally applied to newborns, children and adolescents, allowing us to reach the year 2000 with the entire population younger than 20 years of age protected against hepatitis B. The impact of the vaccine has been dramatic, with a 99% reduction in the number of infected children younger than 15 years of age, as compared with the beginning of the vaccination campaign. In 2000, there were only two reported cases of children with acute hepatitis B in the country. 6) Last, the introduction of methods for the diagnosis of Metabolic Diseases of the Liver, especially for Wilson disease.

National programs are being developed for the care of celiac disease and cystic fibrosis, sponsored by the Mother-Child Department of the Ministry of Public Health. We have nationally produced reagents needed to evaluate gliadin and tissue transglutaminase antibodies. A national multicenter protocol is also in progress for the treatment of hepatitis C.

Today, however, Cuba is suffering from a prolonged embargo (3,4), mainly economic, that limits in multiple ways our social view and greater development, despite the fact that the cold war era has disappeared. The impossibility of obtaining scholarships for our young specialists or acquiring indispensable medicine and equipment (endoscopes, gas chromatographs for breath testing, and portable pH meters and electrodes for esophageal monitoring) from our former traditional market also hinders the medical practice of Cuba's pediatric gastroenterologists, and which I consider are worthy of mention.

I sincerely wish that this piece helps to build new bridges of friendship among the colleagues from the World Federation of Pediatric Gastroenterology, Hepatology and Nutrition, especially among medical professionals of the North American Society for Pediatric Gastroenterology and Nutrition (NASPGN).

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REFERENCES

1. Castaneda C, Escobar MP, Garcia E, et al. Long term study of treatment with recombinant alpha 2B interferon in chronic hepatitis B virus in children and adolescents. GEN 1994; 48 (4): 219–25.
2. Castaneda C, Delgado G, Galindo MA. National hepatitis B Vaccination Program for children and adolescents in Cuba. J Pediatr Gastroenterol Nutr 2000; 31 (suppl 2): S199.
3. Garfield R, Santana R. The impact of the economic crisis and the US embargo on health in Cuba. Am J Public Health 1997; 87 (1): 15–20.
4. Kirkpatrick AF. Role of the USA in shortage of food and medicine in Cuba. Lancet 1996; 348 (9040): 1489–91.
© 2001 Lippincott Williams & Wilkins, Inc.