From 1511 to to its independence in 1898 Cuba was a Spanish colony populated largely by Spanish and black African slaves (slavery was abolished in 1886). Once free of Spanish rule, the Cuban republic came quickly under the rule of dictators such as Gerardo Machado and Fulgencio Batista y Saldivar.
Despite significant corruption and repression under these regimes, a relatively large middle and professional class developed. After years of guerilla war, communist revolutionaries led by Fidel Castro overthrew the Batista regime in 1959. Castro andthe communist government have remained in power since 1959.
Communist changes in government and society led to shifts (but no lessening) in repression, increased literacy rates, changes in land ownership, and increased access to basic health care. The country remains impoverished, especially after the collapse of the Soviet Bloc in the early 1990s.
History of Immigration
One outcome of communist victory in Cuba was a flood of middle and professional class refugees to the United States. Many of these refugees established large Cuban communities in Miami, Tampa, and New York City.
In 1980, the Cuban government allowed 125,266 Cubans, including a number of criminals as well as persons with mental illness, to leave Cuba in the "Mariel boat lift." While most "Marielitos" were healthy and guilty only of wanting to leave a repressive system, this extraordinary event is often seen only as a means of Cuba ridding itself of the mentally ill and criminals. In the 20 years since the Mariel boat lift, 1,425 of the Marielitos have been sent back to Cuba and 1,750 remain in the custody of the U.S. Immigration and Naturalization Service (INS) (Ojito, 2000). Most Marielitos have enjoyed success in the U.S., while others have had greater difficulty than earlier Cubans in establishing themselves.
The most recent large
influx of Cubans was in 1994, when about 30,000 "rafters" reached
the U.S. Since then, the INS has sent all Cubans stopped in the water back
to Cuba, while allowing those who reach land to stay. From the beginning of
modern Cuban immigration of refugees in 1959 and continuing until today, there
have been large numbers of family reunification cases.
Most early Cuban refugees to the U.S. were of Spanish origin, while later refugees and immigrant groups have included more people of mixed or African origin.
Culture and Social Relations
As with other cultures, differences among Cubans exist according to social class, background, ethnicity, and other factors. Although many Cuban refugees are from urban backgrounds, significant numbers will have lived in the city for less than one generation, hence may have more rural than urban outlook on life. Almost forty years of communist rule have resulted in a culture that is definitely Latino in nature, yet to some extent has moved away from such traditional influences as the Catholic Church. For example, in a startling testimony to the power that necessity and Marxism can exert over religion, large numbers of Cuban women have had multiple abortions as a means of birth control.
The extended family is idealized and relatively common among Cubans of all social classes (Blank & Torrechila, 1998). However, in many cases, the nuclear family is the basic unit of social structure. Men usually have the dominant role, but many Cuban women are outspoken and assertive in public and private. Age, social status, and education are respected. Both within and without families, deference may be given to the elderly, persons of higher social status (especially male), and those with higher education.
The language of Cuba is Spanish, though there may be differences between Spanish spoken by Cubans and the Spanish of Mexicans, for example. Many new refugees and immigrants speak only Spanish. Conversation tends to be animated, fast, and may seem loud; and communications within families and among friends often seem warm and affectionate. Direct eye contact is the norm in almost all interactions. Men greet one another with hand shakes and women are often physically affectionate with one another.
Both women and men tend to be passionate and express themselves in a way that may seem demanding to more reserved people. This may result in negative perceptions by health care providers who sometimes expect docility in refugees.
Cubans traditionally are Catholic, but many younger recent refugees and immigrants have had little exposure to religion of any sort. Protestant missionaries (often of "Bible church" or Pentecostal orientation) are very active in Cuban communities in the U.S.
Although Catholicism is the primary religion of Cubans, Santeria is practiced by some Cubans (and others from the Caribbean) in Cuba and the U.S. There is evidence that Santeria is practiced by persons from middle and upper-class backgrounds as well as those with less education. Santeria is based on the Lacumi beliefs of the Yoruba people who came to Latin America as slaves. Santeria incorporates Yoruba gods (the "Seven African Deities") or orishas, Catholic saints, and variations on Catholic ritual. Santeria rituals, a few including animal sacrifice, are conducted by Santeros (priests) or less commonly, by Babalawos (high priests). Herbal formulations and prayer are most commonly used. Healing by blessing rituals (santiquo) include supplications to one of the following orishas and corresponding saint (Pasquali, 1994).
Santeros intervene in both physical and mental illnesses; and seldom operate in conflict with biomedical treatments. When treating mental illness Santeros may ascribe the problem as a special attribute or strength (facultade) of the person being treated.
Health Beliefs and Practices
Traditional Cuban culture holds that mind, body, and spirit are inextricably intertwined. Health is viewed as a sense of well-being, freedom from discomfort, and a robust appearance. Traditionally, many Cubans believe that moderate obesity indicates good health and thinness indicates poor health (Varela, 1996). Traditional diet (fried foods, beans, sweets) contributes to obesity and the wide availability of colas, sweets, and fast foods in the U.S. promotes obesity and attendant health problems. Meat is a valued part of the Cuban diet. Meat was less available in Cuba, but of course is affordable in the U. S., hence large quantities may be consumed, with attendant health problems. Infants and children are often comforted with food and plump infants are viewed as healthy.
While biomedical or allopathic medical practices are widespread in Cuba and germ theory is accepted and understood by most Cubans, traditional and other theories of illness causality are also incorporated in health beliefs and practices. Stress is thought to cause a variety of physical and mental health problems. Supernatural forces (e.g., mal de ojo or evil eye) or a lack of balance are thought by some, especially the less educated, to cause or contribute to physical and mental health problems. Among people who understand germ theory, imbalance may still be seen as the reason why some people become ill from microorganisms and some do not.
Amulets may be worn as protection against supernatural harm. Santeros are utilized in some cases to treat or prevent illness, especially those related to supernatural forces (see discussion under religion above). Regardless of a person's faith (Catholic, Protestant, Santeria, or a blend of these), spiritual care/belief is often incorporated in treatment or explanation of illness. Children, pregnant women, and postnatal women are thought to be especially vulnerable to supernaturally influenced health problems (Pasquali, 1994; Varela, 1996).
Persons who are sick tend to take on a passive and dependent role. Self-care is poorly understood and little accepted. The physician is highly respected and expected to be in a more directive than partnership role. Decision-making usually includes older or more respected family members. Some expect bad news such as a poor prognosis to be shared with the family (oldest immediate family member) before the patient is told. HIV/AIDS diagnosis should be shared only with the patient and only with staff (vs. family or community) translators. Women are expected to provide and be in charge of sick care within the family, including when the patient is hospitalized (Varela, 1996).
The desire for family to be informed about a terminal illness or poor prognosis before the patient has at least the potential to lead to conflict. To avoid conflict it is best to clarify with the patient and family in early contacts that such information is given to the patient unless she or he expressly requests otherwise. It is difficult for patients and families to agree to DNR orders as such orders and acceptance of terminal status may represent giving up and abandonment of the patient.
Hospitalized patients are likely to be attended by family around the clock. Hygiene is important and is best given by the patient her or himself, or by family members. Some will resist shampooing during an illness. Patients will struggle to use the toilet rather than a bedpan. Although Cubans are not excessively modest, modesty for persons who are ill may be an important issue. Both men and women express pain openly, though both may tolerate painful procedures without complaint (Valera, 1996).
Pregnancy and Childbirth
Pregnant women are expected to stay inside if possible and avoid over-exertion. Contact with persons who have deformities or health problems, as well as discussion of these should be avoided during pregnancy. In general, it is best to avoid any potentially stressful or negative discussion with a pregnant woman. Cubans in America are well aware of the value of prenatal care and tend to be early seekers of care. Men may be surprised at the prospect of participating or being present at delivery and the pregnant woman's mother may be surprised at not being allowed to direct the proceedings.
The traditional postnatal
practice is for the new mother and infant to remain inside the home for 41
days after delivery. Women from the family or neighbor women are responsible
for caring for both (and providing food for the father as well) during this
time. Potentially stressful or negative discussions should be avoided. Breastfeeding
is common (Varela, 1996).
Many Cubans prefer circumcision, which is available in public hospitals in Cuba, but is not in some public hospitals in the U.S. Families in which a woman is pregnant should be made aware of this potential problem.
Health Problems and Screening
Most health indicators in Cuba have shown a general improvement over the past several decades. In fact, Cuba has the highest healthy life expectancy (68.4 years) in Latin America, which is near U.S. levels of 70 years (World Health Organization [WHO], 2001). The infant mortality rate is the same in Cuba as in the United States (7.2 per 1000) (Pan American Health Organization [PAHO], 2001). Childhood immunizations (a key reason for improved child mortality rates) are a bright spot in Cuba, with the percentage of children less than one year of age and up-to-date with immunizations exceeding the same population in the U.S. (PAHO, 2001). General mortality in Cuba since the 1950s and 60s is characterized by a shift from communicable diseases to marked predominance of causes associated with chronic noncommunicable diseases. Mortality from diabetes, for example, has more than doubled from 9.9 per 100,000 in the 1970s to 23.4 per 100,000 in 1996 (PAHO, 2001).
Tuberculosis and dengue fever are the infectious diseases of greatest interest among recent refugees and immigrants from Cuba (Guzman, Kouri, Valdes, Bravo, Vazquez, & Halstead, 2002; Marrero, Caminero, Rodriguez, & Billo, 2000; Centers for Disease Control and Prevention [CDC], 2002). Among Cubans there also has been found an unusual "epidemic neuropathy" which manifests as optic neuropathy with loss of central vision, peripheral neuropathy and mixed optic and peripheral neuropathy; and due probably to nutritional deficiencies (Carelli, Ross-Cisneros, & Sadun, 2002; Rodriguez-Hernandez, Hirano, Naini, & Santiesteban, 2001).
The mental health status
of Cuban refugees is probably similar to that of others who come from developing
countries to live in a new and different land. That is, the prevalence of
anxiety and affective disorders is likely to be somewhat higher than in non-refugee
or immigrant populations. There may, in some cases, be higher rates of post
traumatic stress disorder than in non-refugee or immigrant populations (Rothe,
Lewis, Castillo-Matos, Martinez, Busquets, & Martinez, 2002).
The health situation in Cuba is reflected among Cuban refugees and immigrants arriving in the U.S. Most arrive in the U.S. with vaccinations up-to-date or near up-to-date. It is common for middle-aged and older Cubans arriving in the U. S. to present with a variety of untreated chronic illnesses such as diabetes or cardiovascular disease. One health issue seen in the author's clinics but not reflected in the literature is the very high number of Cuban women refugees with a history of multiple abortions as a means of birth control.
Health Risks in Refugees and Immigrants from Cuba (Guzmán & Kourí, 2002; Marrero, Caminero, Rodriguez, & Billo, 2000; PAHO, 2001)
and Other Tests for Refugees and Immigrants from Cuba
There are no specific recommendations for screening Cubans other than the following global recommendations:
Blank, S. & Torrechila, R.S. (1998). Understanding the living arrangements of Latino immigrants: a life course approach. International Migration Review, 32(1), 3-19.
Carelli, V., Ross-Cisneros, F.N., & Sadun, A.A. (2002). Optic nerve degeneration and mitochondrial dysfunction: genetic and acquired optic neuropathies. Neurochemistry International. 40(6), 573-584.
Centers for Disease Control and Prevention [CDC], (2002). Medical examinations of aliens (refugees and immigrants). Accessed 11/10/2002 http://www.cdc.gov/ncidod/dq/health.htm
Guzmán, M.G. & Kourí, G. (2002). Dengue: A update. THE LANCET Infectious Diseases. 2, 33-42.
Guzman, M.G., Kouri, G., Valdes, L., Bravo, J., Vazquez, S. & Halstead, S.B. (2002) Enhanced severity of secondary dengue-2 infections: death rates in 1981 and 1997 Cuban outbreaks. Pan American Journal of Public Health. 11(4), 223-227.
Marrero. A., Caminero, J.A., Rodriguez, R., Billo, N.E. (2000). Towards elimination of tuberculosis in a low income country: the experience of Cuba, 1962-97. Thorax, 55(1), 39-45.
Ojito, M. (April 23, 2000). You are going to El Norte. The New York Times Magazine. 68-73, 78.
Pan American Health Organization (2001). Cuban (Country health profile). Accessed 11/25/2002 http://www.paho.org/English/SHA/prflCUB.htm
Pasquali, E. A. (1994). Santeria. Journal of Holistic Nursing, 12(4), 380-390.
Rothe, E.M., Lewis, J., Castillo-Matos, H., Martinez, O., Busquets, R., & Martinez, I. (2002). Posttraumatic stress disorder among Cuban children and adolescents after release from a refugee camp. Psychiatric Services, 53(8), 970-976.
Varela, L. (1996). Cubans. In J. G. Lipson, S. L. Dibble, & P. A. Minarik (Eds.). Culture & nursing care. San Francisco: UCSF Nursing Press.
World Health Organization
(2001). Healthy life expectancy rankings. Accessed 11/24/2002 http://www.who.int/inf-pr-2000/en/pr2000-life.html
Links Related to Cuba
http://www.paho.org/ Pan American Health Organization ñ an immensely helpful site.
http://cuba.tulane.edu/index.html Tulane University's Cuban Studies Institute.