Sherri L. Porcelain*

Cholera stirred conspicuous fear in the 19th century, prompting the first, of many, International Sanitation Conferences to prevent and control the spread of disease. Even then, and not knowing what caused cholera, countries agreed to cooperate and share health information as a way to reduce the extent of cholera. Today, accelerated migration, trade, travel and tourism underscore the spatial and temporal dimensions to explain a more rapid disease spread. Albeit, now we have improved epidemiology and public health preparation coupled with remarkable advances in scientific and mass media tools to respond to cross border health threats, such as cholera and dengue.

Even with such advancements, there remains a continuing debate if the impetus for these early international meetings were fueled by the fear of disrupting trade and commerce vs. the protection of population health. Consequently, with advanced knowledge, and home to the world-recognized Pedro Kourí Institute of Tropical Medicine founded in 1937, we have to question whether the Cuban government today prioritizes their need for tourism Cuban convertible pesos more than local public health demands?

When a country willfully withholds releasing timely data about a disease outbreak the distinct objective of cross border health cooperation simply ceases to exist. Prioritizing both a country’s legendary reputation to provide health care for all, and a 2.5 billion dollar tourism industry, depicts the paradox of Cuba today. Mobilizing medical diplomacy to resource poor countries has been Castro’s post revolution foreign policy; (1) however, the decisions made to forsake timely sharing of disease outbreaks at home raise important local and global health governance issues. This is an unmistakable reminder that the controversial purpose of the International Sanitary Conference to protect economic health over public health has re-emerged in Cuba, along with cholera and dengue.

To understand the recent outbreaks in Cuba it is instructive to explore the inextricable relationship of three factors: 1) Increase of globalization, travel, and tourism, 2) lack of government transparency, highlighted by the palpable dishonesty of past and current infectious disease outbreaks, and the 3) decline of their public health infrastructure.

The spread of water borne (e.g. cholera) and vector borne (e.g. dengue) diseases is central to the discussion of globalization where trade, business travel, and tourism expose the reality that infectious diseases do not respect borders. The life-threatening microbes and vectors of disease cross borders freely without any documentation of their existence, until they become the unwelcomed visitors. In 2010, Cuba was listed as 9th for the most international tourist arrivals in the Americas reporting a 7% increase this year. (2) Consequently, the loss of tourism and trade dollars presents a clear threat to the health of the Cuban economy.
Dengue and Dengue Hemorrhagic Fever
Dengue and the life threatening form called dengue hemorrhagic fever (DHF) is identified as the most serious mosquito-borne viral disease (3)(4) today. This is transmitted by the bite of an infected agedes aegypt mosquito, and without a vaccine, we must depend upon strategies of prevention. Key issues such as globalization, urbanization, climate change, and natural disasters are some of the contributing factors of D/DHF re-emerging today with an estimated cost of US$ 2.1 billion dollars a year (5) in Latin America and the Caribbean.

The re-emergence of the a.aegypti mosquito has hit Latin America especially hard. Dengue was first recorded in Cuba in late 1820s and followed by the pandemic of 1850. (6) Outbreaks have continued in Cuba in recent times from the 1970s, 1980s -1990s (earlier denied) and once again today. In 1981, Cuba faced the more life threatening form of DHF epidemic with 344,203 people affected 158 dead, of which 101 were children. (7) Cuba has made significant scientific contributions regarding dengue and DHF for other countries to follow. (8)

The concern is not about their scientific knowledge. Rather, the concern is more about Cuba’s official reporting. In late August this year, dissident journalist reported that there were 400 cases of dengue in Camaguey while the government remained silent. (9) We also know more than decade ago health professionals were forbidden to use the words “dengue fever” since the Cuban government maintained an official position that the virus had been eradicated within Cuba’s borders.

No human disease, other than smallpox, has ever been eradicated, and this was only made possible by two key factors: 1) the availability of a vaccine and 2) the impressive global cooperation to immunize individuals. Furthermore, reports of dengue surveillance show increasing spread throughout this hemisphere and on September 26, 2012 the first locally identified case was reported in Miami-Dade County. The deceptive decision to deny the existence of dengue created world attention 12 years ago when Dr. Dessy Mendoza Rivero was incarcerated in Cuba and charged with promoting enemy propaganda when he exposed the dengue fever outbreak to a Miami radio broadcast. A year later the Cuban government did concede, through international pressure, releasing him in exile. Sadly, today the situation does not appear to be much different.


Cholera (vibrio cholerea), and the virulent El tor strain, re-emerged in this hemisphere for the first time in 1991on the Peruvian coast. While it quickly spread throughout South and Central America, Cuba was spared. Absent since 1880, cholera re-emerged in Cuba this summer.

Possibly it was Cuba’s participation in a medical diplomacy mission that brought cholera home. Though it comes as no surprise that it spread once here. The water and sanitation service is “outdated, obsolete, and insufficient to meet the growing national demand for safe drinking water and adequate sanitation services” (10) and according to data used by Belt and Velazquez, the access to piped drinking water was reported as 65% for national population, and sewerage services reaching only 38% of the population. (11)

Less than three weeks after 3 deaths from cholera were officially reported on July 3, 2012, we were told that no new cases of cholera existed. Subsequently new cases appeared. Whether the current Cuban cholera epidemic is blamed on cross border transmission from Haiti during a post- disaster humanitarian mission, or because of in-country tropical storms, flooding, hurricane destruction, climate change, displacement, overcrowding, or economic crisis, the fact is that public health practice begins and ends with a sound infrastructure. In an interview with a former Cuban physician who arrived two years ago, he reminded me that the Oriental region, in Manzanillo, where the cholera deaths were reported, has had a long history of inconsistent potable water. He comments that many residents use their bathtub as a reservoir to store clean water, and emphasizes that the public health infrastructure in Cuba has not garnered the same political will as the medical investments for health facilities that support health tourism and biotechnology research. (12)


Cuba must confront their sewage, sanitation and water issues as part of good public health practice, rather than romanticize about their global health humanitarian efforts abroad. How can the Cuban government use the symbolism of their health tourism and medical diplomacy as a measure of their commitment to local health, when doctors and journalist have been censored or jailed for sharing timely health information? I, as many global public health advocates, was once fascinated by Cuba’s national and global health commitment. Conversely, today, the evidence suggests a clear paradox in Cuba’s cloaked global health diplomacy while the local public health demands remain neglected.


(1) Jack, Andrew. Cuba’s Medical Diplomacy Financial Times, 14 May 2010.
(2) UN World Tourism Organization Report, 2012.
(3) Tapia-Conyer R, Betancourt-Cravioto M, & J Méndez-Galván Dengue: an escalating public health problem in Latin America Paediatric and International Child Health. 2012 May; 32(s1): 14–17
(4) Guzman MG, Halstead SB, Artsob H, Buchy P, Farrar J, Gubler DJ, et al. Dengue: a continuing global threat. Nat Rev Microbiol. 2010;8:S7–16.
(5) Díaz-Quijano FA and Walman EA Factors Associated with Dengue Mortality in Latin America and the Carribean,1995-2009; An Ecological Study Am J Trop Hyg 2012 86:328-334.
(6) Schneider J Droll D A Timeline for Dengue in The Americas o December 31, 2000 PAHO timeline
(7) Guzmán MG Revista Cubana de Medicina Tropical, Vol. 64, No1, Jan-Apr 2012. Thirty Years after the Cuban Hemorrhagic Dengue Epidemic of 1981, MEDICC Review April 2012, Vol. 14, No 2.
(8) Troyo A, Porcelain S, Calderon-Arguedas O, et al. , Dengue in Costa Rica: the gap in local scientific research Rev Panam Salud Publica/Pan Am J Public Health 20(5), 2006.
(9) Tamayo J. Miami Herald 20 August 2012,
(10) Belt JA, Velazquez L Cuba: Reforming the Power, Telecommunications and Water Sectors During a Transition, 2 August 2007, Presented at the Annual Meetings of the Association for the Study of the Cuban Economy (ASCE), Miami, Florida, pdf August 2, 2007.
(11) Belt JA, Velazquez L Cuba: ,, citing from CUBAAGUA/Instituto Nacional de Recursos Hídricos (
(12) Personal Interviews in Miami, October 10-13, 2012.


*Sherri L. Porcelain has taught global public health at the University of Miami for 26 years, and is currently working on a book about US Foreign Policy and Global Health: The Nexus of Infectious Disease. She is a Senior Research Associate at ICCAS.


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