Fear of dengue

For years dengue has been a daily part of life for Cubans. He who has not become ill has had a sick family member or neighbor. In 2019, according to statistics from the Pan American Health Organization (PAHO), 3,259 people had contracted the virus on the Island. It is the highest number of infested persons in the last five years.

“Since the 1990s we have faced dengue epidemics which are always worrisome because the disease is lethal if it is not well attended,” explains retired biologist Flor Ángel Castillo, who specialized in medical entomology and vector control.

After so many years, why is dengue still that stone that we too often stumble over? Where do control strategies fail?

The final stretch

A study conducted, The Evaluation of the Cuban Environment (2009), highlights the main effects of climate change on the country in the period from 2000-2006, and points to a trend of increasing outbreaks of mosquitoes, with the consequent risk of the transmission of dengue.

Aedes aegypti (the mosquito that transmits the disease) moves in tropical regions and urban areas where abundant rain and heat make up its natural habitat. The map where dengue proliferates is almost an overlay of most of the third world from the Philippines to the Caribbean.

Making matters worse, its presence has also been reported further north and south, where it was not supposed to expand. In the Americas alone there were 3,140,649 cases reported at the end of last year (more than in 2017 and 2018).

While there is no specific vaccine or treatment for the virus, “the main thing is to avoid, discover and eliminate mosquito breeding sites. If there is no carrier, there is no transmission,” says Castillo.

However, this preventive medicine —the heart of Cuba’s public health system— seems to have failed with respect to this situation. The zigzag of the contagion indicates that whenever one outbreak is successfully controlled, another reappears. “You expect it every summer: Dengue cases start now because the rains begin,” confirms a doctor from the Salvador Allende Hospital (better known as the Covadonga), whom we will call Dr. Lisette.

The rise and fall of infections corresponds to the scheme designed to face the spread of the virus. When an outbreak arises, “intensive vector control actions are applied until the transmission ceases to be evident,” explains an article in the Cuban Journal of Tropical Medicine. Briefly stated: when the numbers start to emerge, then the confrontation is reinforced.

It’s not a question of prevention. There is just not enough of it.

The number of sick people implies that large resources are allocated towards its control, “but despite this the infestation rates are still high,” say researchers Oneida Terazón and María Terazón.

So far general statistics are not available. In 2016, for example, an intensive campaign exceeded 24 million pesos spent and 8,000 tons of petroleum, according to statements by the then Minister of Public Health, Roberto Morales. Other reports establish that the epidemic in Santiago de Cuba in 1997 entailed a total expenditure of more than $10 million dollars, or approximately $594 per patient.

These figures point to the fact that the bulk of the measures (and the money) is carried out based on the presence of the mosquito, or the infected persons. The response to dengue is concentrated on the side of the effects, while the real causes remain unchanged.

Living with the enemy

The less touristy version of Havana shows a landscape of garbage cans, overflowing sewers and leaks; it includes houses in fair or poor conditions, along with 54,864 inhabitants who receive water via tanker trucks. Sadly, this same scenario is repeated — for better or worse — in other parts of the island.

Until August of last year, 17 percent of the population had running water with a frequency of between 3 and 10 days, and another 3 percent with cycles that ran longer than 10 days. That supposedly tiny 3 percent represents more than 330,000 people.

Time and again, Cuban experts have insisted on the crucial nature of environmental factors. So much so that it seems that everything has already been said.

In 2006, a study determined the habitats used by the mosquito in several Havana municipalities: 14 percent of the outbreaks were in water storage containers for human consumption, and another 12 percent appeared in ditches, manholes, sewers and drains . It is not surprising then that currently about two-thirds of the hatcheries are inside houses.

A study, Dengue Transmission Outbreaks in Population Settlements of Santiago de Cuba, done in 2010, addressed six communities in which irregular access to running water, lack of sewerage, difficulties with solid waste collection and accumulation of non-biodegradable waste, were very frequent. “The deterioration of the environmental conditions generated by these population settlements favors the increase in the rates of infestation by Aedes aegypti, eminently domestic and anthropophilic,” the authors concluded.

Since the mosquito lives in interior spaces, its existence has everything to do with the customs of the people, and what they do. Ariel, for example, felt bad and never went to see a doctor. “Because of the symptoms, I was suspicious and self-medicated: Dipyrone 500 mg every four hours, and a lot of meat.” If a mosquito had bitten Ariel then, it could have also infected many others too.

In order to avoid hospitalization — a recent mandatory practice — there are those who hide the disease. In “high season” packed hospital rooms scare many off due to the sheer number of patients or the hygiene conditions. “I did not go to the hospital because I was afraid they would admit me. It went well because I had no complications, but it should not be this way,” confesses Aylin, who’s also had to deal with the problem of dengue.

Another scientific text published in 2019 describes the breeding ground for the re-emergence of the virus: uncontrolled or unplanned urbanization, inadequate sanitation, poor inter-sectoral coordination, in addition to “the lack of participation by organizations and residents who feel that everything related to that arbovirus constitutes a problem to be solved by the health sector.” Several specialists point out the low perception of risk among people.

“People don’t think they can get sick; that it will happen to others. Not only does it happen in Cuba, but in other countries as well; we see it now in the middle of the pandemic,” says the biologist.

Dengue is classified as a so-called “disease of poverty.” And the evidence confirms that it is often mishandled by the health authorities, blaming those in charge of infrastructure and basic services. If this has been proven, why do the measures not persist there?

Resources are spent anyway at the end of the process. Strict logic suggests attacking dengue before it reappears.

Fear and solutions

Not everyone suffers the same fate — if it can be called that — to go through what is known as a classic dengue. Pregnant women, the elderly, and children make up the so-called risk groups, with greater possibilities of complications, as do people with previous conditions (comorbidities), such as hematological conditions.

“All diseases do not affect people all in the same way,” explains the doctor from Covadonga. You never know if you’ll get complications or just a plain dengue, as we like to say.”

Despite the high number of infections, in 2019 no deaths from dengue were reported in Cuba. However, in previous years there have been deaths. If people delay seeking health care, and are already sick (vomiting, bleeding), the condition may worsen and lead to a state of shock, the most dreaded of complications.

“When dengue shock sets in, there is no way to fix that,” said Dr. Lisette. “I am afraid of dengue because I have treated young people and I have not been able to save them.”

The sustained presence of the virus implies exponential risks. There are four serotypes that have circulated interchangeably during epidemics. The infected person then develops a lifelong immunity to that specific serotype; however, it may relapse if it is later infested with another. And each time you get sick, the effects of the virus become more dangerous.

Dr. Lisette insists that people must know these hidden facts, they must handle statistics. “When you are going to give information by any means, I know that your objective is not to scare people; but you have to report it because things have to change in some way. For me that is one of the aspects for which the population has not become truly aware.”

(The 2017 and 2018 Yearbooks of Statistical Health do not mention the word dengue, for example, in their nearly 200 pages.)

“Despite the fact that the Ministry [of Public Health] and the country are concerned with reducing the level of cases… first, the characteristics of the climate favor it; and second, sanitation measures always fail,” says the doctor. Adding that, in her opinion, the health staff ends up paying the price.

There have been success stories in Cuba in reducing mosquitoes and dengue, although they have been local and / or ephemeral responses.

Between April and July 2011, a community intervention took place in a 26 block area with a very high risk of infestation, in Santiago de Cuba. Various institutions, the government and the residents participated.

In addition to the necessary health well-being, 90 percent of risks detected were eliminated: micro-dumps, houses in danger of collapse, extra-domestic leaks, grasslands and extra-domestic obstructions. Result: the infestation rate plummeted.

“The health sector cannot act alone since most of the determining factors are outside its control, which reveals the need for an inter-sectoral approach,” say four of the doctors who took part in the initiative.

There’s a not often used axiom that states that by doing the same we will get you the same results. A Medical Entomology and Vector Control specialist confirms that it is necessary to review the control programs and update them according to the conditions at all times. All the sustainability that is required for Cuban economic development should also be applied to prevent people from getting sick.