Reemergence of Dengue in Cuba: A 1997 Epidemic in Santiago de Cuba Gustavo Kourí,* María Guadalupe Guzmán,† Luis Valdés,‡ Isabel Carbonel,‡ Delfina del Rosario,
* Susana Vazquez, *José Laferté,* Jorge Delgado,§ and María V. Cabrera‡
*Instituto de Medicina Tropical "Pedro Kourí" (IPK), Marianao, Havana, Cuba; †WHO/PAHO Collaborating Center for the Study of Viral Diseases, Havana, Cuba; ‡Provincial Center for Hygiene, Epidemiology and Microbiology, Santiago de Cuba, Cuba; and §Ministry of Public Health, Cuba

After 15 years of absence, dengue reemerged in the municipality of Santiago de Cuba because of increasing migration to the area by people from disease-endemic regions, a high level of vector infestation, and the breakdown of eradication measures. The 1997 epidemic was detected early through an active surveillance system. Of 2,946 laboratory-confirmed cases, 205 were dengue hemorrhagic fever, and 12 were fatal. No deaths were reported in persons under 16 years of age. Now the epidemic is fully controlled.
Cuba had its first dengue epidemic of modern times in 1977; transmission continued probably until 1981, and more than 500,000 mild cases were reported. A 1978 serologic survey for flavivirus antibody indicated that 44.6% of the Cuban population had been infected with dengue-1 virus, whereas before 1977 only 2.6% had antibodies (1,2).

A second dengue epidemic in 1981, caused by dengue-2 virus (2), was unusually severe and widespread. Of 344,203 cases, 10,312 were clinically classified as dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS), and 158 persons (101 children and 57 adults) died (3). Before 1981, only 60 suspected or confirmed DHF sporadic cases had been reported in the region (4). Dengue-2 virus isolated during the 1981 epidemic was classified in the same genotype as New Guinea
1944 (5). Not previously known to circulate in the Americas, thisgenotype was not isolated again in the region until 1994 in Venezuela and in 1995 in Mexico (6). Retrospective studies show that although the 1981 epidemic was detected in May, the first cases occurred in December 1980. After the epidemic ended on October 10, 1981, a campaign to improve mosquito control and eradicate Aedes aegypti was immediately launched. Eradication was not achieved, but most of the
169 Cuban municipalities were free of the vector.

Passive Surveillance —1981
A passive dengue surveillance system was established at the end of the1981 epidemic. Of 9,543 paired sera (acute- and convalescent-phase)from all suspected dengue patients, only 14 showed seroconversion to immunoglobulin G (IgG) by enzyme-linked immunosorbent assay (ELISA) (7); none developed IgM antibodies to dengue virus by capture IgM ELISA (8). Dengue virus infection was excluded on the basis of clinical and epidemiologic investigation. No Ae. aegypti mosquitoes were found in the residence localities of these patients.

The surveillance system detected cases, imported from other Latin American countries, that had no evidence of indigenous transmission. Since 1987, 4,983 samples received through the surveillance system for measles and rubella, as well as paired sera of patients with rash, were studied for dengue antibodies (María Guzmán, World Health Organization (WHO)/Pan American Health Organization (PAHO) Collaborating Center for the Study of Viral Diseases, unpub.

info.). No dengue cases were identified. The low Ae. aegypti premise indexes and the results of the passive surveillance system indicate no dengue transmission in Cuba between 1981 and the end of 1996. However, reinfestation has occurred in some areas; the municipality of Santiago de Cuba was reinfested in 1992 by Ae. aegypti transported in imported tires (9).
Active Surveillance —1997In January 1997, the Institute of Tropical Medicine "Pedro Kourí" of the Cuban Ministry of Health (a WHO/PAHO Collaborating Center for the Study of Viral Diseases) established an active surveillance system for dengue in Santiago de Cuba municipality. The municipality is located in Santiago de Cuba province, in the eastern part of the country, and has several risk factors for the reemergence of dengue: limited water supply, inadequate eradication efforts, high vector infestation, and increasing migration of people from Latin American and Caribbean disease-endemic countries to the municipality.

Following the Guidelines for the Prevention and Control of Dengue and Dengue Hemorrhagic Fever in the Americas (4), this surveillance system actively searched for febrile patients in the primary health-care subsystem whose clinical picture was compatible with dengue fever and whose sera collected 5 to 6 days after onset of the disease contained dengue IgM antibories. As a result of this system, dengue cases were detected on January 28, 1997, in one area of the municipality.

In three of the first seven cases, dengue-2 virus was detected by polymerase chain reaction (10) and was confirmed by viral isolation and identification using C6/36 cell line and monoclonal antibodies to the four dengue serotypes.
Although retrospective seroepidemiologic studies indicated that the initial transmission occurred during the second half of December 1996, it is highly probable that the cases detected on January 28 were the first. Of 60,000 cases reported from the emergency rooms of Santiago de Cuba hospitals from November 1 to January 28, 592 were clinically compatible with dengue fever. Home interviews of these 592 patients reduced the figure to 154. Blood samples from 143 of 154 patients were examined for IgM antibodies, but no positive cases were detected.

The breakdown of the vector control campaign in this municipality interfered with our efforts to abort the epidemic, despite the early detection of the first dengue cases; however, the partial vector control measures implemented once the outbreak was detected prevented its extension to the other 30 Cuban municipalities infested with the Ae. aegypti mosquito.
Active surveillance continued from January to July 1997. Serologic confirmation of cases was carried out by IgM capture ELISA, confirming recent infection. The serologic diagnosis was decentralized to the Provincial Laboratory in Santiago de Cuba, which used an ultramicro-ELISA for dengue IgM detection (11). The Institute of Tropical Medicine served as the national reference laboratory for serology, viral isolation, and strain identification and characterization.
During the epidemic, 17,114 febrile patients were initially considered to have dengue, but serologic testing of 10,024 of these patients confirmed dengue in only 2,946; 46 dengue-2 isolates from 160 serum samples were obtained. The nucleotide sequence of the E\NS1 gene junction of the first isolated strain (12) indicated that it belonged to the Jamaica genotype, which during recent years is being transmitted extensively throughout Latin American and Caribbean countries and is associated with DHF/DSS in some countries (6,13).

Epidemiology
After the end of the 1981 Cuban DHF epidemic, seroepidemiologic studies in Palmira, Cienfuegos, and Cerro municipalities examined dengue-1 and dengue-2 seroprevalence in these populations (14,15). Taking into consideration these data and the total population of the Santiago de Cuba municipality, we estimated the prevalence of dengue-1 and dengue-2 antibodies. The estimated total population at risk for dengue-2 infection was 301,986 adults and children susceptible to a primary infection by any dengue virus serotype (63.5% of the population) and 88,108 adults with antibodies to dengue-1 virus acquired during the epidemic of 1977 to 1980, now susceptible to a secondary infection with dengue-2 and at increased risk for DHF/DSS (18.5% of the population).
The earlier Cuban experience (3) confirms other reports of secondary infection (dengue-1 and dengue-2) as the main risk factor for DHF/DSS. During the 1997 dengue outbreak, secondary infection was again confirmed as a risk factor for DHF/DSS. Of the 2,946 confirmed cases,
205 (including 12 fatal adult cases) were classified as DHF/DSS casesaccording to the criteria established by PAHO (4). DHF/DSS was observed mostly in adults, the only age group in whom secondary infection was possible. DHF/DSS-compatible symptoms were seen only in one child with primary infection. Preliminary studies indicated that secondary infection was present in 100 (98%) of 102 DHF/DSS cases. In fatal cases, secondary infection could be documented in 11 (92%) of 12 cases. In Thailand the greatest risk appeared when the secondary infection occurred 6 months to 5 years after the primary one (16). For that reason, an epidemic of DHF/DSS was not expected in Santiago de Cuba, perhaps only sporadic cases. However, DHF/DSS in adults who contracted a secondary infection at least 16 years after the primary infection was not previously reported.
Because in Cuba dengue-1 circulated from 1977 to 1980-81, the youngest patients expected to contract secondary infection should be older than
16 years of age; the youngest DHF/DSS patient with confirmed secondaryinfection was a 17-year-old, which indicates that the "enhancing" antibodies can circulate and be effective for at least 16 years and maybe for life.A significant number of febrile patients with suspected dengue had respiratory signs and symptoms; therefore, simultaneous circulation of respiratory or other pathogens was considered. Serologic screening for respiratory viruses using hemagglutination-inhibition and ELISA confirmed that 29.3% of 41 nonconfirmed dengue cases were influenza A, influenza B, or adenovirus infections. Additionally, some children had fever and rash clinically compatible with herpangina, and some had diarrheal disease with fever, as is common in Cuba during the summer.

These febrile syndromes contributed to the high number of patients whose infections were provisionally considered suspect dengue cases. Suspect dengue cases were broadly defined to maximize sensitivity of detection and retain all possible dengue cases. This active surveillance excluded other febrile syndromes but recorded them as suspected cases. In practice, the risk perception by the population was very high, especially when the epidemic was officially declared and deaths were noted.

Both the patients and the health providers appeared to think of dengue as the first diagnostic possibility. For this reason, the figure of 17,114 cases was considered the magnitude of the epidemic from the clinical management perspective. Since most cases were tested serologically, the incidence of clinical cases was probably close to the 2,946 serologically or virologically confirmed cases. Because asymptomatic and subclinical dengue cases are frequent, especially in children, the true rate of infection may be higher.

In a separate and limited study on asymptomatic contacts of dengue cases, for every clinical case, 13.9 asymptomatic or subclinical cases were produced. Serologic studies of contacts in Santiago de Cuba are planned for a more in-depth study of this question.

Clinical Management
The health authorities established a liberal policy of hospitalization that varied with the availability of beds. Hospitalization permitted vector control of the human reservoir, more precise case classification, and close clinical surveillance.
When beds were available, all patients with suspected cases were hospitalized. When the numbers of patients surpassed the availability of beds, patients were treated at home under the supervision of the family doctor. The family doctor transferred the patient to the hospital if any medical complication appeared. Wards with specialized personnel were established where the patients were protected from vectors, and observation wards were organized for patients with complications. Intensive and intermediate care units, as well as an emergency subsystem for the transfer of patients from one unit to another, were available. As in 1981, some patients rapidly developed hypovolemic shock and died within hours of admission to the hospital (17).
An ad hoc task force followed the case definitions for dengue and DHF/DSS established by PAHO (4) for classifying the cases at the closure of the medical record. The accumulated experience of the Cuban scientists and doctors and the increased international knowledge about dengue and DHF/DSS in the last 15 years permitted a much deeper and more comprehensive study of this outbreak with more accurate classification and management of cases than in 1981. Nevertheless, the case-fatality rate was three times higher, mainly because of a much better classification of DHF/DSS cases. Other countries in the region with a very accurate case classification, such as Puerto Rico (13), also have a high case-fatality rate.
Vector Control
The campaign to control the vector started before the beginning of the
1997 dengue outbreak and is well established. Although the campaignrequired the mobilization of scarce financial resources and experts from all over the country, early intervention prevented spread of the outbreak to other potentially vulnerable municipalities. Of 169 municipalities in Cuba, 30 had Ae. aegypti mosquitoes. The epidemic was limited to the municipality of Santiago de Cuba; no autochthonous transmission to other municipalities of the province or country was detected.
An active search for cases detected transmission very early, before "fever alert" signaled an outbreak. In the Provincial Center for Hygiene, Epidemiology, and Microbiology of Santiago de Cuba, a special Unit for Analysis and Trends maintains a permanent fever alert system. For several years, this system has provided a weekly tabulation of febrile patients for every population. The tabulation allows us to evaluate fever alert (4) as applied to an active surveillance system. Because the fever alert did not appear in the epidemic area until May 1997, after the epidemic was already occurring, we consider fever alert an indicator with low sensitivity for the early and timely detection of dengue transmission, at least under the conditions of this study.
As a result of the 1997 epidemic, an epidemiologic alert was established, and antivector intervention, as well as active seroepidemiologic surveillance, was reinforced in the entire country. The epidemiologic characterization of the outbreak (now fully controlled) is in the final phase. Although mosquitoes persisted at a low level after the 1981 DHF/DSS epidemic, the campaign was successful in eradicating dengue from Cuba for more than 15 years, precisely when the disease was reemerging in nearly all the other tropical regions of the Americas. According to PAHO, 250,707 cases of dengue fever and 4,440 cases of DHF/DSS were reported in 1996 alone; 29 countries reported dengue in 1996, and 10 of these reported DHF/DSS. Overall, from 1981 to 1996, 25 countries reported 41,000 cases of DHF/DSS (F. Pinheiro, pers. comm.).
The 1997 Cuban dengue outbreak demonstrated once again that dengue reappears where Ae. aegypti control is relaxed. Taking into account these facts, Cuba maintains its policy of vector eradication and recommends an exerted effort in the American region to prevent a recurrence of dengue similar to the one in Southeast Asia, where DHF/DSS is the leading cause of hospitalization and death among children (18).
References
Cantelar N, Fernández A, Albert L, Pérez E. Circulación de dengue en Cuba 1978-1979. Rev Cubana Med Trop 1981;33:72-8.
Kourí G, Mas P, Guzmán MG, Soler M, Goyenechea A, Morier L. Dengue hemorrhagic fever in Cuba, 1981: rapid diagnosis of the etiologic agent. Bull Pan Am Health Org 1983;17:126-32.
Kourí G, Guzmán MG, Bravo J, Triana C. Dengue hemorrhagic fever/dengue shock syndrome: lessons from the Cuban epidemic. Bull World Health Organ 1989;67:375-80.
Dengue and dengue hemorraghic fever in the Americas: guidelines for prevention and control. Washington: Pan American Health Organization;
1994. Scientific publication No. 548.Guzmán MG, Deubel V, Pelegrino JL, Rosario D, Sariol C, Kourí G. Partial nucleotide and amino-acid sequences of the envelope and the envelope/nonstructural protein-1 gene junction of four dengue 2 virus strains isolated during the 1981 Cuban epidemic. Am J Trop Med Hyg 1995:52:241-6.
Ricco-Hesse R, Harrison LM, Salas RA, Tovar D, Nisalak A, Ramos C, et al. Origins of dengue type 2 viruses associated with increased pathogenicity in the Americas. Virology 1997;230:244-51. Fernández R, Vázquez S. Serological diagnosis of dengue by an ELISA inhibition method (EIM). Mem Inst Oswaldo Cruz 1990;85:347-51. Vázquez S, Saenz E, Huelva G, González A, Kourí G, Guzmán MG. Detección de IgM contra el virus del dengue en sangre entera absorbida en papel de filtro. Rev Panamericana de Salud Pública. In press 1998. Ministerio de Salud Pública de Cuba. Dengue en Cuba. Julio 1997. Boletín Epidemiológico Organización Panamericana de la Salud 1997;18:7.
Lanciotti RS, Calisher CH, Gubler DG, Chang G, Vordam V. Rapid detection and typing of dengue viruses from clinical samples by using reverse transcriptase-polymerase chain reaction. J Clin Microbiol 1992;30:545-51.
Laferte J, Pelegrino JL, Guzmán MG, González G, Vázquez S, Hermida C. Rapid diagnosis of dengue virus infection using a novel 10µl IgM antibody capture ultramicroELISA assay (MAC UMELISA Dengue). Advances in Modern Biotechnology 1992;1:19.4.
Rico-Hesse R. Molecular evolution and distribution of dengue viruses type 1 and 2 in nature. Virology 1990;174:479-93.
División de Prevención y Control de Enfermedades, Programa de Enfermedades, Programa de Enfermedades Transmisibles, HCP/HCT, OPS. Resurgimiento del dengue en las Américas. Boletín Epidemiológico. Organización Panamericana de la Salud 1997;18:1-6. Guzmán MG, Kourí G, Bravo J, Hoz de la F, Soler M, Hernández B. Encuesta seroepidemiológica retrospectiva a virus dengue en los municipios Cienfuegos y Palmira. Rev Cubana Med Trop 1989;41:321-32. Guzmán MG, Kourí G, Bravo J, Soler M, Vázquez S, Morier L. Dengue hemorrhagic fever in Cuba, 1981: a retrospective seroepidemiologic study. Am J Trop Med Hyg 1990;42:179-84.
Halstead SB. Observations related to pathogenesis of dengue hemorrhagic fever. Yale J Biol Med 1970;42:350-60. Díaz A, Kourí G, Guzmán MG, Lobaina L, Bravo J, Ruiz A, et al. Description of the clinical picture of dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) in adults. Bull Pan Am Health Organ 1988;22:133-44.
Gubler DJ, Clark GG. Dengue/dengue hemorrhagic fever: the emergence of a global health problem. Emerg Infect Dis 1995;1:55-7.

http://www.cdc.gov/ncidod/EID/vol4no1/kouri.htm
1 2
This article is actually very postive coverage of the handling of the 1997 outbreak. It was, in fact, published in a Centers for Disease Control peer reviewed journal (link below). There is no indication that the outbreak was in anyway mishandled. Quite the contrary. This CDC report begins:

"After 15 years of absence, dengue reemerged in the municipality of Santiago de Cuba because of increasing migration to the area by people from disease-endemic regions, a high level of vector infestation, and the breakdown of eradication measures. The 1997 epidemic was detected early through an active surveillance system. Of 2,946 laboratory-confirmed cases (0.03% of the island's population), 205 were dengue hemorrhagic fever, and
12 were fatal. No deaths were reported in persons under 16 years of age. Nowthe epidemic is fully controlled."
So much for the fearmongers that have ingratiated themselves with the foreign media!
A year later, Fidel received the UN's World Health Organization's Health for All Medal for Cuba's contributions in the field of public health. Some years later, even the conservative, Washington-based World Bank was forced to concede that Cuba is doing a "great job" in health care (and education). And that Cuba's remarkable achievements in these areas would NOT be sustainable under a capitalist regime a stunning admission from these high priests of neo-liberal ideology!
See Featured Article, "What do Cubans stand to lose, and who stands to gain?" at my website.
Dan
Visit my CUBA: Issues & Answers website at
http://www.netcom.ca/~dchris/CubaFAQ.html
This article is actually very postive coverage of the handling of the 1997 outbreak. It was, in fact, published in ... Fidel received the UN's World Health Organization's Health for All Medal for Cuba's contributions in the field of public health.

Lancet Volume 352, Number 9143 05 December 1998 Cuban "prisoner of conscience" doctor released but exiled
The doctor who was imprisoned for reporting on the 1997 Cuban dengue epidemic has been pardoned by the government.
Desi Mendoza Rivero was released from jail last week, on condition that he immediately leave the country. Last year, Mendoza was charged with disseminating enemy propaganda after he alleged that Cuba's government was covering up the epidemic for political reasons and to prevent damage to tourism.
His statements, which were disseminated by international media, were one of the only sources of information on the epidemic. The first official report was provided to WHO some 6 months after cases of dengue fever were initially identified.
Ironically, Mendoza's reports have been mostly confirmed by the final official description of the epidemic published in the January­March, 1998, issue of Emerging Infectious Diseases
(http://www.cdc.gov/ncidod/EID/vol4no1/kouri.htm).

Mendoza was jailed for 8 years in November, 1997, and was adopted as a "prisoner of conscience" by Amnesty International (see Lancet 1998; 351: 441). His health has reportedly suffered greatly during his imprisonment. It is understood that Spanish foreign Minister, Abel Matutes, had specifically requested the release of several political prisoners, including Mendoza, during his visit to the country last month.
Media sources report that Mendoza's pardon was granted "for humanitarian reasons"; the move is being viewed by some as a goodwill gesture in advance of an historic Spanish Royal visit to the island. The Cuban government has released an unprecedented number of prisoners this year, in response to pleas made by the Pope on his visit in January.
But, as with Mendoza, many are exiled as an obligatory condition of their release. Mendoza has been granted political asylum by Spain, and travelled there last week, apparently accompanied by family members. Kelly Morris
This article is actually very postive coverage of the handling ... Medal for Cuba's contributions in the field of public health.

Lancet Volume 352, Number 9143 05 December 1998 Cuban "prisoner of conscience" doctor released but exiled The doctor who was ... after he alleged that Cuba's government was covering up the epidemic for political reasons and to prevent damage to tourism.

As we can see from the CDC article, the epidemic was in no way mishandled from a public health perspective. It only enhanced Cuba's reputation as a world leader in health care. This guy, Mendoza, head of some so-called "independent" (US-financed?) dissident association, exaggerated the death toll early in the epidemic for what would appeared to be political reasons.

Dan
Visit my CUBA: Issues & Answers website at
http://www.netcom.ca/~dchris/CubaFAQ.html
1997 peer was Santiago cases and Now for

Lancet Volume 352, Number 9143 05 December 1998 Cuban "prisoner ... epidemic for political reasons and to prevent damage to tourism.

As we can see from the CDC article, the epidemic was in no way mishandled from a public health perspective. (snip)

False.
From Promedmail, an orgainzation of independent doctors that link up world-wide:
"Reports continue to come to ProMED-mail regarding dengue in Cuba. We have not received complete and offical explanations of what appear to be certain clinical aberrations, and now we have a report of the arrest of an apparently
well-known Cuban physician for reporting cases.
CubaPress (http://www.cubapress.com/) carried the following article, translated roughly into English:
DOCTOR WHO INFORMED ON EPIDEMIC ARRESTED
Havana, CubaPress, 25th June. State Security agents arrested Dr. Dessy Mendoza, 42 years old, a prominent specialist in general medicine at 6:10 pm Wednesday.
(clip)
Moments before these events, Doctor Mendoza said to CubaPress: "Without a doubt they are looking for me so that I don't keep revealing to the national and international public the true magnitude of the dengue epidemic in Santiago, but I will keep doing this as long as I am free". At the same time he informed us that that the so called hospitalito (= "little hospital")
of the Boniato prison had accepted two prisoners sick with dengue, bringing the number of cases registered in this penal institution to 18.

This physician has been responsible for much of the valuable information that has obliged the regime to acknowlege the existence of the epidemic and, although tardily, to take measures to try to prevent its propagation in other
parts of the country.
(c) CubaPress/Report from Havana Ricardo Gonzalez Alfonso for CubaPress."
If there is no large-scale epidemic of dengue in Cuba, then there would be no
reason to arrest anyone for reporting one. If there is such an epidemic, then it seems the responsibility of Cuban authorities to report it fully.

If the 7-year old who died from dengue had dengue hemorrhagic fever, this might indicate that the disease has not been absent from Cuba during the past seven years.
People emigrating from Cuba or visiting Cuba, including international health representatives, have reported that it is in line with Cuban Government policy to report mild cases of dengue as "influenza". Cuban physicians have confirmed allegations that some disease reporting in Cuba is politically
influenced (e.g., if dengue were declared wiped out, then physicians could report the disease only as influenza-like symptoms). However, lack of reporting may simply be an understaffing issue.
The Cuban authorities had reported the eradication of two mosquito species thought by many outside Cuba to be ineradicable. Eradication of both Ae. aegypti and Ae. albopictus is a difficult, if not impossible task, no matter the resources applied. Quiet requests by Cuba for additional insecticide foggers and almost 200 tons of insecticide did not go unnoticed, but did indicate that neither Aedes mosquitoes nor dengue had been eradicated
from Cuba.
Aerosol treatment from airplanes and land vehicles is reported to be the method of choice for mosquito eradication in Cuba, yet this method has been shown to be ineffective in controlling dengue because:

(a) Aedes aegypti mosquitoes spend most of their time indoors and (b) Aedes aegypti and Ae. albopictus do not breed in swamps and other natural sites (such as ditches dug for defensive purposes), they breed in containers, usually man-made containers.
If, as has been reported, water has been rationed in some parts of Cuba, then it is certainly possible that water storage containers could be serving as breeding sites for Aedes mosquitoes.
The fine virologists at Instituto "Pedro Kouri" in Havana are certainly capable of making definitive laboratory diagnoses of dengue, and the Cuban vector control people have the reputation of being among the best, if not the
best, in their area of expertise.
This morning's CubaPress reported that the epidemic of dengue is continuing in Santiago de Cuba, that there have been 10,000 - 30,000 cases, with perhaps

3 - 15 deaths, depending on who is providing the information. Of course,this is only a report by a news service. WHO and the PanAmerican Health Organization (WHO's Regional Office for the Western Hemisphere) cannot report
to the world without clearance from the Cuban government. Their last report,
of 18 June 1997, stated: "On 16 June 1997, the Ministry of Health officially reported that 826 cases of dengue (3 deaths) have occurred in the city of Santiago de Cuba."
Until we have an official update, all we have are rumors. It would be best for all concerned to have definitive data from responsible authorities in Cuba, and I am certain that the readers of ProMED-mail, world-wide, would welcome such a report.
Surely the U.S. Army, which has a base at Guantanamo, could provide some information about the presence or absence of dengue in that area?
Moderator, ProMED-mail
Archive Number 19970627.1390
Published Date 27-JUN-1997
Subject PRO/EDR> Dengue/DHF - Cuba (06)
http://www.promedmail.org /
A ProMED-mail post

(see also:
Dengue/DHF - Cuba: doctor sentenced 971125175143)
Date: Mon, 22 Jun 1998 13:17:24 GMT-3

ProMED-mail has been advised that a colleague is in imminent danger of prosecution for divulging details of an epidemic in the interest of world public health.
This reminds us that it is almost one year since Dr. Desi Mendoza Rivero was detained for alleging that the Cuban authorities were covering up the true extent of a dengue fever epidemic. Amnesty International said of his case, "Expressing views which are at odds with official positions is no reason to be taken to court."
Forty-three-year-old Dr. Mendoza has been in detention since his arrest on
25 June 1997, and last November he was sentenced to 8 years in prison.Representations asking for his release from Amnesty International, Physicians for Human Rights, and the Pope himself have been unavailing.

It is notable that countries are becoming more open about reporting outbreaks, in the interest of global public health. China reported all human cases of the 'chicken flu,' influenza A H5N1, without delay. Thailand is now admitting, after years of denial, that they have cholera. Nowhere, with the single exception of Cuba, have we heard of anyone being imprisoned for carrying out their duty as a physician to report publicly matters affecting the public health.
It should be a cause for serious concern, and for strong representations by public health representatives and governments worldwide, if anyone else were to be prosecuted for reporting publicly on current public health emergencies. There is no room for official secrets when it comes to matters of life and death in the health arena.

Director, ProMED-mail
Director, Nucleus for Investigating Emerging Infectious Diseases Institute for Biomedical Sciences
Federal University of Rio de Janeiro
Brazil
Archive Number 19980622.1162
Published Date 22-JUN-1998
Subject PRO> Official secrets and public health
Official secrets and public health 980622185032)
Date: Tue, 23 Jun 1998 15:45:02 -0500

As a general matter in international health law and international human rights law, there is no recognized specific human right to disseminate public health information nationally or to the rest of the world. Dissemination of public health information falls under established areas of human rights law such as free speech. As a historical matter, WHO has proved uninterested in human rights issues, and only really woke up to their public health importance during the AIDS pandemic. The new Health for All policy recently adopted by the World Health Assembly stresses the importance of human rights in public health policies, which is a positive development for WHO.
Now, virtually all the major international human rights treaties allow freedom of speech to be restricted for public health reasons (as well as other compelling public interests). (Let's assume, for analytical purposes, that Castro thinks arresting and imprisoning Mendoza is necessary for public health reasons to ensure accurate dissemination of public health information.) It is widely recognized that to justify a restriction on the freedom of speech, the restriction must (1) be prescribed by law, (2) be applied in a nondiscriminatory manner, (3) relate to a compelling public interest, and (4) be necessary to achieve the compelling public interest, meaning that the restriction has to be proportional to the interest sought to be protected, and be the least restrictive measure possible to achieve the public interest in question.

One might argue in favor of the restriction that trade and tourist industries can be hurt very badly if a private physician circulates misleading or false public health information internationally. But this argument only works with misleading or false information, not with true information.
The historical reluctance of governments to report public health information (which is one of the reasons the International Health Regulations have not worked well) creates the potential for government repression of efforts to disseminate public health information through non-official channels.
While the Mendoza case raises important public health concerns, it also intersects more standard international human rights discourses. As the involvement of Amnesty International and Physicians for Human Rights in the Mendoza case suggests, the Castro government's actions against him can be faulted for violating recognized norms of international human rights law such as the right of free speech. But Castro's government has never recognized a right of free speech.
The machinery for enforcing international human rights law is notoriously weak. In addition, the enforcement machinery is treaty based, and Cuba is unlikely to have joined many international human rights treaties.

This is an issue for the World Health Assembly to address, and WHO as a whole. But I think that the best strategy is a two-pronged assault from the international human rights angle and the public health angle. Amnesty International and other human rights NGOs have already become involved, but the Mendoza case should also be brought before the Inter-American Commission on Human Rights, which has cited Castro's government for violating human rights in the past.
In addition, WHO needs to challenge Castro formally and publicly on this issue. The fact that it just awarded Castro a Gold Medal for Health for All in May 1998 does not bode well for WHO taking action on this issue, or for its handling of human rights in general.

David P. Fidler, JD
Indiana University Law School
Indiana, USA
(This is something for the new WHO Director-General to take up - Mod.JW)

Archive Number 19980625.1180
Published Date 25-JUN-1998
Subject PRO> Official secrets and public health (02)

More here on the cover up:
In 1997 the dengue epidemic in Santiago was hidden in order not to endanger "el Festival del Caribe ni
Expo-Caribe'97".
Doctors were instructed NOT to diagnose and report the life threathening strain of dengue.
PROHIBIERON DIAGNOSTICAR LA ENFERMEDAD"En marzo, declaró el presidente del Colegio Médico Independiente de Santiago de Cuba-las autoridades sanitarias prohibieron a los médicos diagnosticar el dengue. No querían que lo supieran-continuó el doctor Mendoza-ni los pacientes, ni familiares, pues las autoridades consideraron la epidemia como una cuestión política, para evitar que la información llegara al extranjero y afectara el turismo. Además, las compañías que suministraban insecticidas y equipos de fumigar aumentarían los precios".

Respecto a esta prohibición de diagnóstico, el doctor Dessy Mendoza aseguró a CubaPress que varios profesionales de la salud de Santiago de Cuba se han acercado al Colegio Médico Independiente que él preside par manifestar su descontento por esa disposición. "No pueden manifestarse públicamente pues saben que serían víctimas de represalias, pero estos profesionales con una valiosa fuente de información, expresó el doctor Dessy Mendoza Rivero. También se supo que no se han suspendido ni el Festival del Caribe ni Expo-Caribe'97, eventos programados para esta semana en la referida ciudad oriental.
http://www.cubanet.org/CNews/y97/jun97/26a3.htm
THEY FORBADE TO DIAGNOSE THE DISEASE
" In March, the president of the Independent Medical School of Santiago
of Cuba declared the sanitary authorities forbade the doctors to diagnose
dengue. They did not want that the patients to know it continued doctor
Mendoza nor family members, because the authorities considered the epidemic as a political question, to avoid that the information would become
known abroad and affect the tourism. In addition, the companies that provided to insecticides and equipment to fumigate would increase their
prices ".
With respect to this prohibition of diagnosing (dengue), doctor Dessy Mendoza assured to CubaPress that several health professionals in Santiago
of Cuba have turned to the Independent Medical College that he presides over
to show their ouutrage with respect to that order. " They cannot speak out
publicly because they know that they would become victims of retaliation,
but these professionals with a valuable source of information, expressed
doctor Dessy Mendoza Rivero. It also became knwon that neither the Festival
of the Caribbean nor Expo-Caribé97, events programmed for this week in the
Eastern city referred to, have been cancelled."
See :
"The Ministry of Health does everything in its power to conceal such evidence, even supplying false figures to the World Health Organization, in order not to discredit the Cuban health services.' "

From a Pax Christi report :
See : http://www.cubacenter.org/media/archives/1998/spring/pope visits.php3
From Amnesty International:
21 NOVEMBER 1997Cuba: Doctor facing 13-year sentence for 'propaganda'
Amnesty International is today calling for the immediate and unconditional release of Cuban doctor and prisoner of conscience, Desi Mendoza Rivero, who is facing a possible 13-year sentence next Monday for using the mass media to spread "enemy propaganda".
If you are a UK based journalist and require further information please call the AIUK Press Office on 0171 814 6238 or e-mail
"Desi Mendoza Rivero was detained simply for accusing the Cuban authorities of covering up the true extent of a dengue fever epidemic and of not taking sufficient measures to control it," Amnesty International said today. "Expressing views which are at odds with official positions is no reason to be taken to court."
Forty-three-year-old Dr Mendoza, who has been in detention since his arrest on 25 June 1997 and is currently held in Boniato Prison, just outside Santiago de Cuba, was tried in that city on 18 November. Sentencing is expected on 24 November. The basis of the charge against him was that he had issued statements, which were later disseminated by foreign newspapers and broadcast media, regarding an epidemic of dengue fever in Santiago de Cuba which, according to him, had caused several deaths.
According to reports of the six-hour trial, the prosecution requested a 13-year sentence for Dr Mendoza, who was able to speak on his own behalf for some 40 minutes. His lawyer refuted each of the allegations against him and refrained from requesting a lower sentence on the grounds that in his view Dr Mendoza had committed no crime. When several members of the public applauded the lawyer's statement, they were removed from the courtroom.
All media in Cuba are state-controlled and dissidents are frequently arrested and imprisoned for speaking out against the government and criticizing its policies. In 1994, Dr Mendoza founded the Colegio Médico Independiente de Santiago de Cuba, Santiago de Cuba Independent Medical Association, an unofficial organization not recognised by the Cuban authorities of which he is president, and it is believed that the action against him may be at least partly in reprisal for his peaceful activities with that organisation.
See : http://www.amnesty.org.uk/news/press/releases/november 1997-20.shtml

PL
Now

Health

for As we can see from the CDC article, the epidemic was in no waymishandled from a public health perspective. (snip)

False. From Promedmail, an orgainzation of independent doctors that link up world-wide: "Reports continue to come to ProMED-mail regarding dengue ... clinical aberrations, and now we have a report of the arrest of an apparently well-known Cuban physician for reporting cases.

(snip more of the same)
This still does undermine the fact that the epidemic was well handled from a public health perspective. The international medical community recognized it as such (previous posting). The rest is all politics.
This morning's CubaPress reported that the epidemic of dengue iscontinuing in Santiago de Cuba, that there have been 10,000 - 30,000 cases, with perhaps 3 - 15 deaths, depending on who is providing the information.

(snip)
This was supposedly at the beginning of the epidemic. Clearly some initial reports were wildly exaggerated for political purposes, no doubt. The final numbers posted in the peer reviewed CDC journal are 2,946 cases with
12 deaths by the END of the epidemic.

Dan
Visit my CUBA: Issues & Answers website at
http://www.netcom.ca/~dchris/CubaFAQ.html
See Featured Article, "What do Cubans stand to lose, and who stands to gain?" at my website.

I'll be sure to do that. Emotion: rolleyes
Cordially,
Gene Ledbetter
See Featured Article, "What do Cubans stand to lose, and who stands to gain?" at my website.

I'll be sure to do that. Emotion: rolleyes Cordially, Gene Ledbetter

There you can enjoy comrade Dan's "creative writing". Emotion: rolleyes

"Today, for the first time, Amnesty International has explicitly denounced
the US embargo on Cuba in humanitarian terms, and made clear its support for
the immediate and unconditional lifting of these cruel sanctions"

http://members.allstream.net/~dchris/CubaFAQ.html
Link to the "report":
http://web.amnesty.org/library/Index/ENGAMR250172003?open&of=ENG-CUB

They aren't calling for an "immediate and unconditional" end to the trade
sanctions in that report. Aren't they?
Dan snipped the words "immediate and unconditional" from these sentences in the report (THE ONLY PLACES WHERE THEY ARE USED):

"in 1.
"On the basis of the available information, therefore, Amnesty International considers the 75 dissidents to be prisoners of conscience(2) and calls for their immediate and unconditional release."
In 8.1
"· to immediately and unconditionally release the 15 prisoners previously named by Amnesty International as prisoners of conscience.

· to immediately and unconditionally release anyone else who is detained or imprisoned solely for having peacefully exercised their rights to freedom of expression, association and assembly."

and added to those snippets your own words to create this sentence on his lying website:
" Amnesty International has explicitly denounced
the US embargo on Cuba in humanitarian terms, and made clear its support for
the immediate and unconditional lifting of these cruel sanctions"

that sentence:

1. isn't in the report
2. isn't supported by the tenure and the conclusions of the report

He snipped two three words used by Amnesty to condemn the Castro regime and
abused them in a sentence to imply support for your cause: a BLATANT LIE.
What the report actually recommends about the "embargo" is:

"Amnesty International calls on the United States government

· to immediately suspend decisions on any measures that could toughen the embargo.
· to review its foreign and economic policy towards Cuba, with an aim towards ending this damaging practice.
· to place enjoyment of the full range of human rights at the forefront of its concerns in developing new policy towards Cuba."

Clearly no immediate and unconditional end is demanded as Dan claims. The request is for not stiffening the sanctions and to review a policy that places "enjoyment of the full range of human rights at the forefront of its concerns".
See:
http://web.amnesty.org/library/Index/ENGAMR250172003?open&of=ENG-CUB
PL
Dan: See Featured Article, "What do Cubans stand to lose, and who Dan: stands to gain?" at my website.
Me: I'll be sure to do that. Emotion: rolleyes
There you can enjoy comrade Dan's "creative writing". Emotion: rolleyes Dan snipped the words "immediate and unconditional" from these sentences in ... to condemn the Castro regime and abused them in a sentence to imply support for your cause: a BLATANT LIE.

I am shocked that Dan would have done such a dishonest thing. My unshakable faith in Dan's every word has been crushed.

Good detective work, PL!!!
Gene Ledbetter
Mostrar más