RESUMO Objetivo. Quantificar a associação entre a prevalência de controle populacional da hipertensão e mortalidade por doença cardíaca isquêmica (DCI) e acidente vascular cerebral (AVC) em 36 países das Américas, de 1990 a 2019. Métodos. Este estudo ecológico utilizou os dados de prevalência da hipertensão e prevalência da detecção, tratamento e controle populacional da hipertensão do estudo NCD-RisC, e de mortalidade por DCI e AVC do Estudo de Carga Global de Doença de 2019. Análise de regressão foi utilizada para avaliar as tendências no tempo e a associação entre controle populacional da hipertensão e mortalidade. Resultados. Entre 1990 e 2019, as taxas de mortalidade padronizadas por idade devidas a DCI e AVC diminuíram anualmente 2,2% (intervalos de confiança de 95%: −2,4 a −2,1) e 1,8% (−1,9 a −1,6), respectivamente. A taxa anual de redução na mortalidade por DCI e AVC desacelerou para −1% (−1,2 a −0,8) durante o período de 2000-2019. De 1990 a 2019, a prevalência de hipertensão controlada com pressão arterial sistólica/diastólica ≤140/90 mmHg apresentou aumento anual de 3,2% (3,1 a 3,2). O controle populacional da hipertensão apresentou associação inversa com mortalidade por DCI e AVC, respectivamente, em toda a região, e em todos os 36 países, com a exceção de três. Em toda a região, para cada 1% de aumento no controle populacional da hipertensão, nossos dados previram uma redução de 2,9% (−2,94 a −2,85) nos óbitos por DCI por 100 000 habitantes, equivalente à prevenção de 25 639 óbitos (2,5 óbitos por 100 000 habitantes), e de 2,37% (−2,41 a −2,33) nos óbitos por AVC por 100 000 habitantes, equivalente à prevenção de 9 650 óbitos (1 óbito por 100 000 habitantes). Conclusão. Existe forte associação ecológica negativa entre mortalidade por DCI e AVC e controle populacional da hipertensão. Os países com o melhor desempenho no controle da hipertensão mostraram melhor progresso na redução da mortalidade por doenças cardiovasculares. Os modelos de previsão têm implicações no controle da hipertensão na maioria das populações da Região das Américas e em outras partes do mundo.

RESUMEN Objetivo. Cuantificar la asociación entre la prevalencia de control de la hipertensión arterial a nivel poblacional y la mortalidad por cardiopatía isquémica y accidente cerebrovascular en 36 países y territorios de la Región de las Américas entre 1990 y el 2019. Métodos. Este estudio ecológico emplea la prevalencia de la hipertensión, la concientización, el tratamiento y el control de la hipertensión arterial en la población producidos por la Colaboración sobre Factores de Riesgo de las Enfermedades No Transmisibles (NCD-RisC, por su sigla en inglés) y estimaciones de mortalidad por cardiopatía isquémica y accidente cerebrovascular del estudio sobre la carga mundial de enfermedad del 2019. Se realizó un análisis de regresión para evaluar las tendencias temporales y la asociación entre el control de la hipertensión arterial en la población y la mortalidad. Resultados. Entre 1990 y el 2019, las tasas de mortalidad estandarizadas por edad a causa de cardiopatía isquémica y accidente cerebrovascular disminuyeron en 2,2% (intervalos de confianza de 95%: –2,4 a –2,1) y 1,8% (–1,9 a –1,6) anual, respectivamente. La tasa de reducción anual de la mortalidad por cardiopatía isquémica y accidente cerebrovascular se redujo a –1% (–1,2 a –0,8) entre el 2000 y el 2019. Del 1990 al 2019, la prevalencia de hipertensión arterial controlada definida como presión arterial sistólica/diastólica ≤140/90 mmHg aumentó anualmente en 3,2% (3,1 a 3,2). Se observó una relación inversa entre el control poblacional de la hipertensión y la mortalidad por cardiopatía isquémica y por accidente cerebrovascular, respectivamente, en toda la Región y en los 36 países, a excepción de tres. En toda la Región, por cada aumento de 1% en el control de la hipertensión arterial en la población, nuestros datos predijeron una reducción de 2,9% (–2,94 a –2,85) en las muertes por cardiopatía isquémica por 100 000 habitantes, equivalente a 25 639 muertes evitables (2,5 muertes por 100 000 habitantes) y de 2,37% (–2,41 a –2,33) en las muertes por accidente cerebrovascular por 100 000 habitantes, equivalente a 9 650 muertes evitables (una muerte por 100 000 habitantes). Conclusiones. Existe una sólida asociación ecológica negativa entre la mortalidad por cardiopatía isquémica y accidente cerebrovascular y el control de la hipertensión arterial en la población. Los países con mejor resultado en el control de la hipertensión mostraron un mayor progreso en la reducción de la mortalidad por enfermedad cardiovascular. Los modelos de predicción tienen implicaciones en el manejo de la hipertensión en la mayoría de los grupos poblacionales de la Región de las Américas y otras partes del mundo.

ABSTRACT Objective. To quantify the association between the prevalence of population hypertension control and ischemic heart disease (IHD) and stroke mortality in 36 countries of the Americas from 1990 to 2019. Methods. This ecologic study uses the prevalence of hypertension, awareness, treatment, and control from the NCD-RisC and IHD and stroke mortality from the Global Burden of Disease Study 2019. Regression analysis was used to assess time trends and the association between population hypertension control and mortality. Results. Between 1990 and 2019, age-standardized death rates due to IHD and stroke declined annually by 2.2% (95% confidence intervals: –2.4 to –2.1) and 1.8% (–1.9 to –1.6), respectively. The annual reduction rate in IHD and stroke mortality deaccelerated to –1% (–1.2 to –0.8) during 2000-2019. From 1990 to 2019, the prevalence of hypertension controlled to a systolic/diastolic blood pressure ≤140/90 mmHg increased by 3.2% (3.1 to 3.2) annually. Population hypertension control showed an inverse association with IHD and stroke mortality, respectively, regionwide and in all but 3 out of 36 countries. Regionwide, for every 1% increase in population hypertension control, our data predicted a reduction of 2.9% (–2.94 to –2.85) in IHD deaths per 100 000 population, equivalent to an averted 25 639 deaths (2.5 deaths per 100 000 population) and 2.37% (–2.41 to –2.33) in stroke deaths per 100 000 population, equivalent to an averted 9 650 deaths (1 death per 100 000 population). Conclusion. There is a strong ecological negative association between IHD and stroke mortality and population hypertension control. Countries with the best performance in hypertension control showed better progress in reducing CVD mortality. Prediction models have implications for hypertension management in most populations in the Region of the Americas and other parts of the world.

ABSTRACT Non-communicable diseases (NCDs) represent one of the greatest challenges for development of the 21st century due to their devastating social, economic and public health impact. The objective of this article are to describe the evolution and risk factors for NCDs in Cuba, mainly in the period 1990–2015, to outline actions undertaken by the Ministry of Public Health of Cuba, and to highlight the most important challenges with a focus on their prevention and control. The information is based on data collected and published by the Directorate of Medical Records and Health Statistics, research on risk factors, other studies and documentation of comprehensive actions. Mortality in Cuba is determined by four major health problems: cardiovascular diseases, malignant tumors, chronic diseases of the lower respiratory tract and diabetes mellitus, which together cause 68.0% of deaths. Cancer presents a growing trend, and chronic kidney disease emerges as a serious health problem. Cuba has a known baseline on risk factors, and hypertension and tobacco consumption are the main factors related to NCDs mortality. In line with the importance of these diseases, there are milestones and interventions with a positive impact, as well as gaps and challenges within the framework of the World Health Organization’s Global Action Plan for the Prevention and Control of NCDs.

RESUMEN Las enfermedades no transmisibles (ENT) representan uno de los mayores desafíos para el desarrollo en el siglo XXI, debido al devastador impacto social, económico y de la salud pública que provocan. El propósito de este artículo es describir la evolución y los factores de riesgo de las ENT en Cuba, principalmente en el período 1990–2015, reseñar las acciones emprendidas por el Ministerio de Salud Pública y destacar los desafíos más importantes para su prevención y control. La información contenida proviene de los datos colectados y publicados por la Dirección de Registros Médicos y Estadísticas de Salud, investigaciones sobre los factores de riesgo, otros estudios fundamentados y la documentación de acciones integrales. La mortalidad en Cuba está determinada por cuatro grandes problemas de salud: enfermedades cardiovasculares, tumores malignos, enfermedades crónicas de las vías respiratorias inferiores y diabetes mellitus, que en conjunto causan el 68,0% de los fallecimientos. La tendencia del cáncer es al ascenso y la enfermedad renal crónica emerge como un grave problema de salud. Cuba cuenta con una línea de base conocida sobre los factores de riesgo, de ellos la hipertensión y el consumo de tabaco son los principales relacionados con la mortalidad por ENT. En consonancia con la importancia de estas enfermedades se aprecian hitos e intervenciones de impacto positivo, así como brechas y desafíos en el marco del Plan de Acción Mundial de la Organización Mundial de la Salud para el enfrentamiento a las ENT.

RESUMO As doenças não transmissíveis (DNT) representam um dos maiores desafios do século 21 para o desenvolvimento devido ao desvastador impacto social, econômico e de saúde pública que elas causam. O objetivo deste artigo é descrever a evolução e os fatores de risco das doenças não transmissíveis em Cuba, principalmente no período de 1990–2015, para delinear as ações realizadas pelo Ministério da Saúde Pública de Cuba e destacar os desafios mais importantes para sua prevenção e controle. A informação vem dos dados coletados e publicados pela Diretoria de Registros Médicos e Estatísticas de Saúde, pesquisa sobre fatores de risco, outros estudos fundamentados e documentação de ações abrangentes. A mortalidade em Cuba é determinada por quatro principais problemas de saúde: doenças cardiovasculares, tumores malignos, doenças crônicas do trato respiratório inferior e diabetes mellitus, que em conjunto causam 68,0% das mortes. O câncer tem uma tendência crescente, e a doença renal crônica surge como um grave problema de saúde. Cuba tem uma linha de base conhecida sobre os fatores de risco, dos quais a hipertensão e o consumo de tabaco são os principais relacionados à mortalidade por DNT. Em consonância com a importância dessas doenças, há marcos e intervenções com impacto positivo, bem como lacunas e desafios no âmbito do Plano de Ação Mundial da Organização Mundial da Saúde para enfrentar as doenças não transmissíveis.

The Strategic Plan of the Pan American Health Organization, 2014-2019, Championing Health: Sustainable Development and Equityrecognizes that "Chronic kidney disease, caused mainly by complications of diabetes and hypertension, has increased in the Region." This Plan includes the first concrete goal on chronic kidney disease: to achieve a prevalence rate for renal replacement therapy of at least 700 patients per million population by 2019. National dialysis and transplant registries (DTR) are a useful tool for epidemiological research, health care planning, and quality improvement. Their success depends on the quality of their data and quality control procedures. This article describes the current situation of national DTRs in the Region and the content of their information and health indicators, and it offers recommendations for creating and maintaining them. It points to their heterogeneity or absence in some countries, in line with the inequities that patients face in access to renal replacement therapy. The complete lack of information in Caribbean countries prevents their inclusion in this communication, which requires immediate attention.

El Plan Estratégico de la Organización Panamericana de la Salud, 2014-2019, En pro de la salud: Desarrollo sostenible y equidad, reconoce que "La enfermedad renal crónica causada principalmente por las complicaciones de la diabetes y la hipertensión ha aumentado en la Región". En él se define por primera vez una meta concreta sobre la enfermedad renal crónica: alcanzar una prevalencia del tratamiento de sustitución de la función renal de por lo menos 700 pacientes por millón de habitantes en 2019. Los Registros de Diálisis y Trasplante (RDT) nacionales constituyen una herramienta útil para la investigación epidemiológica, la planificación de la atención de salud y la mejora de su calidad. Su éxito depende de la calidad de sus datos y los procedimientos de control de calidad. En este artículo se describen la situación actual de los RDT nacionales de la Región, sus contenidos informativos e indicadores de calidad, y ofrecen recomendaciones para crearlos y mantenerlos. Se destaca su heterogeneidad o ausencia en algunos países en consonancia con las inequidades de acceso a los tratamientos de reemplazo renal que afrontan los pacientes. La carencia total de información en países del Caribe impide incluirlos en esta comunicación, lo que requiere inmediata atención.

Cardiovasculardiseases are the leading cause of death in the Region of the Americas, making cardiovascular risk assessment a critical component of the clinical decision-making process. This process is facilitated by the use of appropriate tools. Thisarticle presents the technical characteristics of an application (app) developed by the Pan American Health Organization/World Health Organization (PAHO/WHO) for mobile devices and computers. Called the Cardiovascular Risk Calculator, it is based on WHO risk tables and applied to the countries of the Region. The article details the epidemiological basis of the diagram for predicting cardiovascular risk and describes the app and its four modules, its main audiences, its production process, and finally, the initial results and some of the challenges. Fourmonths after its launch, the application was being used daily by more than 12 000 users and had been downloaded in virtually all the countries of the Region. The app can be used in by physicians, nurses, and other technical personnel in their daily practice, especially at the primary care level. Since it can also be used by the general public, special attention was paid to its design and tutorial and to ensuring that the clinical estimates and recommendations were easy to understand. This type of app facilitates communication between health care providers and users, and its systematic use in the health services, especially in primary care services, should be promoted.

Las enfermedades cardiovasculares son la principal causa de muerte en la Región de las Américas. La evaluación del riesgo cardiovascular es un componente crítico del proceso de toma de decisiones clínicas y este proceso se facilita con la utilización de herramientas apropiadas. Se presentan las características técnicas de una aplicación (app) para dispositivos móviles y computadoras producido por la Organización Panamericana de la Salud/Organización Mundial de la Salud, llamada Calculadora de Riesgo Cardiovascular, basada en las tablas de riesgo de la OMS y aplicada a los países de la Región. Se exponen los fundamentos epidemiológicos que subyacen al diagrama de predicción de riesgo cardiovascular, una descripción de la aplicación y de sus cuatro módulos, las audiencias primarias, su proceso de producción y, finalmente, los primeros resultados y algunos de los desafíos. A los cuatro meses de su lanzamiento la aplicación estaba siendo utilizada diariamente por más de 12 000 usuarios y había sido descargada en prácticamente todos los países de la Región. La aplicación se puede utilizar en la práctica diaria de médicos, enfermeras y otro personal técnico, especialmente en el primer nivel de atención. Dado que también puede ser utilizada por el público en general, se prestó especial atención a su diseño y su tutorial, y a que las estimaciones y recomendaciones clínicas fueran fáciles de entender. Este tipo de aplicación facilita la comunicación entre los proveedores de atención sanitaria y los usuarios y es necesario promover su uso sistemático en los servicios de salud, en especial en los servicios de atención primaria.

INTRODUCTION:Over the last 40 years, high smoking prevalence has been reported throughout Cuba, including in Cienfuegos city in the central part of the island. OBJECTIVE: Determine smoking prevalence and potential associated risk factors in Cienfuegos city for 2010-2011. METHODS: A descriptive cross-sectional study was conducted in Cienfuegos city in the context of CARMEN (Collaborative Action for Risk Factor Prevention & Effective Management of Non-communicable Diseases), a PAHO multi-country initiative for a multidimensional approach to chronic non-communicable diseases. Participants totaled 2193 (aged 15-74 years), randomly selected through complex probabilistic three-stage sampling. Variables examined in relation to smoking included age, sex, skin color, civil status and educational level. RESULTS: Approximately 25% of those surveyed were smokers (30.3% of men and 21.0% of women). For men, prevalence was highest in the groups aged 25-34 and 55-64 years; for women, in the group aged 45-54 years. Concerning skin color, smoking rates were higher among black and mestizo persons (29.5%); and concerning civil status, higher among those who were separated, widowed or divorced (30.0%). Smoking prevalence fell with higher educational level; in keeping with that trend, the university-educated group had the lowest prevalence (16.2%). CONCLUSIONS: Although one in four Cienfuegos residents aged > 15 years smoked in 2010-2011, prevalence there is lower than in previous surveys. Knowledge of differences observed in age, sex, skin color, civil status and educational level can be useful for planning future smoking prevention and control actions.

This paper contextualizes the chronic kidney disease epidemic and related burden of disease affecting Central American farming communities. It summarizes the two main causal hypotheses (heat stress and agrochemicals), draws attention to the consequences of dichotomous reasoning concerning causality, and warns of potential conflicts of interest and their role in "manufacturing doubt." It describes some methodological errors that compromise past study findings and cautions against delaying public health actions until a conclusive understanding is reached about the epidemic's causes and underlying mechanisms. It makes the case for a comprehensive approach to the historical, social and epidemiological facts of the epidemic, for critically assessing existing studies and for enhanced rigor in new research.

One of the most common shortcomings in non-communicable disease risk factor surveillance, especially in prevalence studies, is sampling procedure, which can and does compromise accuracy and reliability of derived stimates. Moreover, sampling consumes significant time and resources. Since the early 1990s, risk factor surveys in Cienfuegos province, Cuba have paid particular attention to careful sampling methods. The new survey conducted in 2011 was not only statistically rigorous but introduced an innovative, more effi cient method. This article provides a detailed description of the sample design employed to optimize resource use without compromising selection rigor.

Between 1994 and 2009, the Dr Gustavo Aldereguía University Hospital of Cienfuegos, Cuba implemented a series of interventions that reduced acute myocardial infarction case fatality rate from 47% to 15%. These interventions were part of an institutional plan for myocardial infarction included in the hospital's overall quality assurance strategy. Outcomes resulted primarily from organizational changes (from upgrading of the hospital emergency department and provincial emergency system to creation of a comprehensive coronary care unit and a chest pain center); optimizing use of effective drugs (streptokinase, aspirin, ACE inhibitors and beta blockers); adherence to clinical practice guidelines; and continual and participatory evaluation and adjustment.

OBJECTIVE: To compare the usefulness for surveillance of the peer-reviewed literature on the prevalence of hypertension in Latin America and the Caribbean published from 2001 to 2010 with a previous study of the published literature from 1962 to 2000. METHODS: A bibliographic search was conducted of publications from 2001 to 2010 that examined the prevalence of hypertension using MEDLINE and LILACS databases. The methodology of each paper was evaluated with the same critical appraisal tool used in the previous study. RESULTS: A total of 81 papers were published from 2001 to 2010 on the prevalence of hypertension in Latin America and the Caribbean. Only 24 of these studies met the minimum methodologic criteria for evaluation. While the total number of studies published in the past 10 years exceeds the number published from 1962 to 2000, the percentage of studies that met the minimum methodologic criteria has not substantially increased. In addition to major methodologic shortcomings, less than 46% of the published studies reported rates of awareness, treatment, and control of hypertension. The hypertension prevalence estimates from the peer-reviewed literature range from 7% to 49%. These studies were primarily done in urban centers and are not evenly distributed throughout the region. CONCLUSIONS: The quality and geographic distribution of the published literature on the prevalence of hypertension in Latin America and the Caribbean are inadequate. Research resources and efforts should be directed in the future toward closing this gap.

OBJETIVO: Comparar la utilidad para la vigilancia epidemiológica de los artículos sobre prevalencia de hipertensión en América Latina y el Caribe publicados en revistas con arbitraje científico del 2001 al 2010, con un estudio anterior de la bibliografía publicada en el período 1962-2000. MÉTODOS: En las bases de datos MEDLINE y LILACS se efectuó una búsqueda bibliográfica de los artículos que examinaron la prevalencia de hipertensión publicados del 2001 al 2010. La metodología empleada en cada artículo se valoró con la misma herramienta de evaluación usada en el estudio anterior. RESULTADOS: Del 2001 al 2010 se publicaron 81 artículos sobre la prevalencia de la hipertensión en América Latina y el Caribe. Solo 24 de estos estudios cumplieron los criterios metodológicos mínimos para la evaluación. Aunque en los 10 últimos años se publicaron más estudios que en el período 1962-2000, el porcentaje de estudios que cumplieron los criterios metodológicos mínimos no aumentó sustancialmente. Además de presentar deficiencias metodológicas importantes, menos de 46% de los estudios publicados incluyeron información sobre la concientización, el tratamiento y el control de la hipertensión. Las estimaciones sobre la prevalencia de hipertensión en los artículos estudiados varían entre 7% y 49%. Estos estudios se realizaron principalmente en centros urbanos y no se distribuyeron de manera uniforme en toda la región. CONCLUSIONES: La bibliografía publicada sobre la prevalencia de la hipertensión en América Latina y el Caribe es insuficiente para ser útil con fines de vigilancia, y su calidad y la distribución geográfica son inadecuadas. En el futuro, los recursos y los esfuerzos de investigación deben enfocarse en reducir esta diferencia.

Population aging, smoking, unhealthy diet and physical inactivity, in the context of globalization and unregulated urbanization, explain the high prevalences of hypertension, hypercholesterolemia and diabetes in the Americas, making cardiovascular diseases the main cause of death. Moreover, cardiovascular diseases and their risk factors disproportionately affect the poorest people, obstructing antipoverty efforts and further deepening health and other inequities. The global crisis of chronic non-communicable diseases has reached such proportions that the UN General Assembly called a high-level meeting in September 2011 to address the issue as one of human development, aiming to stimulate political commitment to a concerted global effort to stem the pandemic. In reference to the Americas, this article reviews the burden of cardiovascular diseases and describes priorities for strategies and action in the region and their relation to the results of the UN meeting.

The recommendations from the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) were compared with those of a recent article by Aram V. Chobanian, Chairman of the JNC 7. The purpose was to identify the changes that this author proposed and determine how they might affect clinical work, as well as the health services and public health implications. The JNC 7 and the article in question coincide on all essential points, except that the article is more flexible when it comes to the use of diuretics at the start of treatment for high blood pressure. Chronic disease management should take place in health systems with primary care approach, where the epidemiology of such diseases and scientific advances in prevention offer an excellent opportunity for redesigning the health services and making them more effective. High blood pressure, as a public health problem, demands health interventions aimed not only at reducing harm but modifying its etiologic determinants. The challenge is to recognize that an integrated approach to clinical medicine, health services, and public health would offer an attractive opportunity to interrupt and prevent the continuous and costly vicious circle that managing high blood pressure and its complications implies.

Se contrastaron las recomendaciones contenidas en el séptimo informe del Comité nacional conjunto para la prevención, detección, evaluación y tratamiento de la hipertensión arterial (JNC 7) con un artículo reciente de Aram V. Chobanian, quien fuera presidente del JNC 7. El propósito fue identificar cuáles son los cambios propuestos por este autor y cómo podrían afectar la actuación clínica, así como sus implicaciones en los servicios sanitarios y la salud pública. El JNC 7 y el mencionado artículo coinciden en todos los puntos esenciales, con la excepción de que este último es más flexible en la utilización de diuréticos para iniciar el tratamiento de la hipertensión arterial (HTA). Se considera que la atención de las enfermedades crónicas debería inscribirse en sistemas de salud con un enfoque de atención primaria, donde la epidemiología de tales enfermedades y los avances en la prevención ofrecen una excelente ocasión para rediseñar y hacer más efectivos los servicios de salud. La HTA, como un problema poblacional, requiere de intervenciones sanitarias orientadas no solo a conjurar los daños sino a modificar sus determinantes etiológicos. El desafío es reconocer que un enfoque integrado de medicina clínica, servicios de salud y salud pública, proporcionaría una atractiva oportunidad para interrumpir y prevenir el continuo y costoso círculo que supone el manejo de la HTA y sus complicaciones.

One of the most important consequences of the epidemiological transition that the populations have undergone in the last decades is the progressive and geometric increase in the number of persons suffering chronic diseases; particularly around 80% of people who die from these diseases do not live in developed countries. Growing population aging is added to a setting full of new conditions and "unhealthy" lifestyles. This paper emphasized that for the health services to be successful in the prevention and control of chronic diseases and the care of those affected by them, it is required to clearly define and identify this problem with its specificities, to re-direct the services and to re-design the formation of integral health professionals. All these actions should be carried out in a coordinated way by both public health specialists, epidemiologists and clinicians, within an unprecedented demographic and epidemiological setting in the history of mankind.

Como una de las consecuencias más importantes de la transición epidemiológica que han sufrido las poblaciones en las últimas décadas, ha estado el incremento progresivo y geométrico de las personas que padecen enfermedades crónicas, con la particularidad de que alrededor del 80 % de todos los que mueren de estas enfermedades, no residen en los países desarrollados. A un escenario con nuevas condiciones y estilos de vida "no saludables", se une un envejecimiento poblacional creciente. En este artículo se insiste en que para un enfrentamiento exitoso de los servicios de salud en la prevención y el control de las enfermedades crónicas y en la atención de quienes las padecen, se requiere de una clara definición e identificación de este problema con sus particularidades, de una reorientación de los servicios y del rediseño de una formación de profesionales de la salud integrales; acciones que deberían llevarse a cabo de manera coordinada, tanto por salubristas y epidemiólogos, como por clínicos, en un contexto demográfico y epidemiológico sin precedentes en la historia de la humanidad.

One of the most important consequences of the epidemiological transition that the populations have undergone in the last decades is the progressive and geometric increase in the number of persons suffering chronic diseases; particularly around 80% of people who die from these diseases do not live in developed countries. Growing population aging is added to a setting full of new conditions and "unhealthy" lifestyles. This paper emphasized that for the health services to be successful in the prevention and control of chronic diseases and the care of those affected by them, it is required to clearly define and identify this problem with its specificities, to re-direct the services and to re-design the formation of integral health professionals. All these actions should be carried out in a coordinated way by both public health specialists, epidemiologists and clinicians, within an unprecedented demographic and epidemiological setting in the history of mankind.

Como una de las consecuencias más importantes de la transición epidemiológica que han sufrido las poblaciones en las últimas décadas, ha estado el incremento progresivo y geométrico de las personas que padecen enfermedades crónicas, con la particularidad de que alrededor del 80 % de todos los que mueren de estas enfermedades, no residen en los países desarrollados. A un escenario con nuevas condiciones y estilos de vida "no saludables", se une un envejecimiento poblacional creciente. En este artículo se insiste en que para un enfrentamiento exitoso de los servicios de salud en la prevención y el control de las enfermedades crónicas y en la atención de quienes las padecen, se requiere de una clara definición e identificación de este problema con sus particularidades, de una reorientación de los servicios y del rediseño de una formación de profesionales de la salud integrales; acciones que deberían llevarse a cabo de manera coordinada, tanto por salubristas y epidemiólogos, como por clínicos, en un contexto demográfico y epidemiológico sin precedentes en la historia de la humanidad.

The first assessments of the Millennium Development Goals of the United Nations have been completed, and deliberations about world health are increasing. Now is an appropriate time to consider the case of Cuba, which has functioned under difficult conditions for many years, and followed its own path. Cuba's health indicators are much better than might be expected considering its level of income; in many cases the indicators compare to those of industrialized countries. These results should be viewed as the product of a well-defined strategy and the use of essential public health principles rather than as the accumulation of better numbers. The Cuban experience demonstrates that a population's health can improve in even the most adverse economic conditions. This is attainable when sound public health practices are implemented under the principle that health is a basic right and therefore a national priority. An understanding of the Cuban public health system can help other low-income countries adapt these practices to their own conditions and meet the Millennium Development Goals. If this were to occur, there would be substantial improvement in the world's health.