|Year : 2015 | Volume
| Issue : 2 | Page : 54-60
Steps towards sustainable and resilient disaster management in Japan: Lessons from Cuba
Kenji Isayama1, Naoya Ono2
1 Department of Medical Science and Technology Course of Emergency Medical Technology, Hiroshima lnternational University, Higashi Hiroshima, Hiroshima, Japan
2 Center for Lifenhance in 22nd Century, Institute for Future Engineering, Tomiokabashi, Fukagawa, Koto-Ku, Tokyo, Japan
|Date of Web Publication||12-Feb-2015|
Department of Medical Science and Technology Course of Emergency Medical Technology, Hiroshima lnternational University, 555 36, Kurose Gakuendai, Higashi Hiroshima-739 2695, Hiroshima
Source of Support: None, Conflict of Interest: None
Cuba is a hurricane-prone island in the Caribbean. Hurricanes are endemic to Cuban history. A major hurricane occurs in the country every few years, causing the destruction of homes but very few deaths. Though Cuba has limited economic resources, its healthcare system has managed to solve some problems that the Cuban population itself was unaware of. Furthermore, Cuba has an excellent record with respect to disaster preparedness and response, involving warnings and evacuations, in which governmental control of the population and the efficient organization of society by the state are effectively used to minimize the potential morbidity and mortality from hurricanes. Their unusual healthcare and disaster resilience strategy addresses these problems in ways developed based on Cuba's peculiar political and economic history. However, these systems created in terms of healthcare teams for all, an early focus on prevention and clear attention to community resilience may also inform progress in Japan. This review was conducted using resources from libraries and search engines using specific keyword combinations. The 50 most relevant publications from 2002 to 2014 are reviewed in detail. Though Cuba certainly faces many challenges such as an unsustainable conventional healthcare system, an aging society and economic vulnerability, Cuban disaster risk management incorporates preventive principles, education and community resilience. Similarly, Japanese disaster management should shift focus from emergency response to preventive strategies such as those in the Cuban disaster management plan and Hyogo Framework for Action. Moving towards more sustainable and resilient disaster management in Japan is essential.
Keywords: Cuba, disaster management, healthcare, Hyogo framework for action, Japan
|How to cite this article:|
Isayama K, Ono N. Steps towards sustainable and resilient disaster management in Japan: Lessons from Cuba. Int J Health Syst Disaster Manage 2015;3:54-60
|How to cite this URL:|
Isayama K, Ono N. Steps towards sustainable and resilient disaster management in Japan: Lessons from Cuba. Int J Health Syst Disaster Manage [serial online] 2015 [cited 2020 Sep 30];3:54-60. Available from: http://www.ijhsdm.org/text.asp?2015/3/2/54/151300
| Introduction|| |
Cuba is a hurricane-prone island in the Caribbean region;  hurricanes are endemic to Cuban history.  Cuba's isolation and economic problems were caused by the dissolution of the Soviet Union and exacerbated by the US embargo, making it very complex to solve Cuba's problems.  Even now, the country's economic and social policies continue to adapt to the complex realities of globalization and ongoing US hostility.  The Cuban economic crisis has increased people's vulnerability to the risk of natural disasters, such as hurricanes, in various sectors. 
Conversely, the Cuban healthcare system seems remarkable. There are many physicians and each person has a family physician. The system is tightly organized and its top priority is prevention.  In reality, despite facing a crisis, the Cuban economy could satisfy basic needs, including free healthcare and education.  Although Cuba has limited economic resources, its healthcare system has managed to solve problems that the Cuban population was itself unaware of.  Undoubtedly, improved health outcomes are largely the result of better nutrition and education, which address the social health determinants.  Furthermore, Cuba has an excellent record regarding disaster preparedness and response involving warnings and evacuations, in which governmental control of the population and the effective organization of society by the state are used effectively to minimize the potential morbidity and mortality caused by hurricanes.  Surprisingly, the economic crisis has not affected Cuba's success in protecting lives from hurricanes.  The unusual healthcare and disaster resilience strategy addresses these problems in ways that developed from Cuba's peculiar political and economic history. However, these systems that they have created in terms of healthcare teams for all, an early focus on prevention and clear attention to community resilience may also inform progress in Japan.  Since the 2005 'Hyogo Framework for Action' (HFA) was developed by the United Nations International Strategy for Disaster Reduction (UNISDR) [Table 1],  Cuba has intensified efforts to reduce vulnerability to hazards by mitigating a disaster's potential impact. 
This review was conducted using resources from libraries, websites, Japanese articles and search engines, including Google, Google Scholar and PubMed, using the keyword combinations of Cuba, healthcare, primary care, disaster management, disaster resilience and community-based disaster risk reduction. The 50 most relevant publications from 2002 to 2014 were reviewed in detail and are included herein.
This paper focuses on the Cuban healthcare system and disaster management strategy and reconsiders sustainable and resilient disaster management in Japan on the basis of lessons learned from Cuba and the HFA priority actions.
| Medicine and Health in Cuba|| |
Overcoming the severe limitations of access to healthcare and preventive medicine has been Cuba's major goal since 1959, after which the infant mortality rate has dropped dramatically.  The Cuban literacy rate is 99.8%,  and health education is mandatory in the school curriculum.  [Table 2] shows the difference in health status among the population of Cuba, Japan, the US and the UK. Although Cuba is a developing country, its under-five mortality rate is lower than that of the US. , Cuban life expectancy at birth (for both sexes) is the same as that of the US, but lower than that of Japan and the UK. ,, According to World Bank data, Cuba has around three times as many physicians per person as Japan. 
|Table 2: Difference in health status among populations of Cuba, Japan, the US and the UK|
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The most revolutionary idea of the Cuban health system is family physicians living in the neighbourhoods wherein they practice.  Physician and nurse teams are part of the community and know their patients well because they live at the consultorio where they work. Consultorios are backed by policlinicos (polyclinics), which provide services during off hours and have a wide variety of specialists.  Polyclinics coordinate community health services and link nationally designed health initiatives with their local implementation.  Each team is responsible for improving and maintaining the health status of 120-160 families.  Supervision for family physicians' offices is also centered in the polyclinics; each clinic supports 20-40 family physician and nurse teams. 'Basic Work Groups' comprise a leader from the polyclinic, a nursing supervisor, primary healthcare specialists, including obstetricians and gynaecologists, paediatricians, internists and psychologists and are represented in almost every Cuban community [Figure 1];  in many cases, a social worker is responsible for a specified number of family physician and nurse teams.  Cuba is still a developing country facing serious problems because of limited resources.  Therefore, modern western medicine, disaster medicine, public health and traditional medicine/complementary and alternative medicine have become compulsory subjects in the medical curriculum.  Cuba has been forced to seek a sustainable healthcare system and shift to promotion of healthcare policies with a focus on prevention. 
The most important factor was the primary healthcare approach. Family physician and nurse teams are an integrated part of their neighbourhood, where their work is both supported and evaluated by the community.  Community healthcare in Cuba is a unique aspect of the Cuban healthcare system with a focus on community-based and universally integrated care.  This has been a positive experience in coping with the effects of disasters.  Simple hygiene and basic health education can be much more efficient than belated intervention by many experts.  Everyone's participation is most characteristic of preventive healthcare in Cuba.  The Cuban primary healthcare and social work systems are pivotal to the country's national disaster planning, preparation, response and recovery. 
| Natural Disaster Preparedness in Cuba|| |
Disaster policy and response
A major hurricane affects Cuba every few years, causing the destruction of homes but resulting in very few deaths.  The benefits of universal education and illiteracy eradication are that the population is aware of the risks associated with hurricanes and understands government warnings. Measures for the effective use of human and technological resources to reduce damage include timely advice to the population via all possible means and planned and preventive evacuation of the high-risk population that includes pregnant women, people with disabilities and the elderly. 
Cuban disaster response is partially centered on a highly professional and effective meteorological service and warning system and on mass educational efforts that alert people about impending tropical storms and hurricanes. ,, Cubans are highly educated, have a strong sense of solidarity and social cohesion and are extensively experienced in mobilization and highly organized mass organizations, professional groups and political structures. 
Community shelters are established in schools and community buildings at the beginning of the 'alarm' stage where they receive stocks of water, medicines and supplies. The different heads of government ministries cooperate closely. Each shelter has a director, deputy, physician, nurse, psychologist, veterinarian for pets and police and Red Cross representatives. 
Each municipality compiles detailed biographical information of all citizens annually, including name; age; physical needs; special services required; and the number of infants, pregnant women and persons with disabilities. Another important component of the disaster relief plans is identifying vulnerable housing units and infrastructure. 
All Cubans are well-informed on what to expect from the government once their system predicts the onset of a particular natural disaster and are familiar with the full cycle of activities, including reducing risks, planning logistics for emergencies and responses, preparing communication networks, providing early warnings and regularly reinforcing training.  When a cyclone is predicted, the government first transmits warnings, then alerts, as the danger grows imminent, followed by emergency alarms and finally provides guidance to inform recovery.  People are educated with respect to precautions concerning what to avoid and the steps to be taken during each phase of preparation, emergency response and recuperation. 
Warning and preparation
Cuba has an efficient meteorological service and effective warning systems. , [Table 3] presents the four stages of Cuba's early warning system (EWS).  This information is systematically updated by the risk reduction management centers, which evaluate the risks of disasters nationally.  The EWS simultaneously monitors the natural and technological variables that can develop into risks for the population and economy.  Weather reports are usually broadcast every 6 hours, but there are broadcasts every 3 hours as storms approach.  Cuban hurricane warnings reach 96% of TV viewers and 97% of radio listeners, who are adequately prepared to evacuate based on education and training.  Furthermore, in each of these phases and according to the hurricane's location and strength, the population is informed of the steps to be taken.  Evacuation of the vulnerable population to shelters can guarantee their safety.  The combination of early warnings, preparation and healthcare following the hurricane is essential. ,
| Community-based Disaster Resilience|| |
Civil defense system
Cuba dramatically improved its capacity for protection, emergency response and recovery from natural disasters by creating a national civil defense system (CDS) in 1966.  Cuba is a highly organized society with dense social networks functioning as readymade communication networks.  The reliance of civil defense on local leadership optimizes local knowledge, strengthens cohesion and enhances participation within the community.  In particular, public education and awareness are important roles for healthcare workers throughout the system, beginning with family physicians and nurses.  This is part of a larger effort coordinated by the civil defense system, which involves schools, work centers, mass media, social organizations and others. 
The annual disaster exercise
Every year in May, before hurricane season starts, Cubans participate in their respective ministries, schools, workplaces and hospitals in a two-day mandatory training exercise for risk reduction during hurricanes.  All citizens participate in the annual Meteoro Disaster Preparedness and Response Exercise, which tests national and local readiness with participatory activities relevant to the respective localities.  The Meteoro is also conducted by the CDS.  The Cuban health system participates in the annual, nationwide Meteoro and the national emergency plans are continually updated and simulated annually. 
Schooling is compulsory till the ninth grade and higher education is readily accessible and free. Therefore, all Cubans can access educational material concerning disasters.  All children are exposed to disaster preparedness in their school curricula, which are used as a key vehicle for educating children about disasters.  These factors have important implications in public awareness, participation and organization regarding disaster management. 
The key to the system is educating the community. Even small children participate in drills, learn first-aid and survival techniques, often through cartoons and learn to grow herbal medicines and find food, should disaster strike.  At school, children are also given leaflets providing information about emergencies.  Disaster prevention, preparedness and response are part of school curricula and included in many university curricula. 
Culture of safety
The Cuban population is educated in disaster preparedness through media messages from the Cuban Red Cross and formal education in school, all of which form the 'Culture of Safety'.  These policies have also produced 'multiplier effects' that enhance risk reduction in many ways.  The Cuban experience demonstrates that risk management systems should consider supporting the intangible relationship between training and education.  With this mindset, maximizing resources, creating cooperative structures, using grass-root level resources and creating a 'Culture of Safety' becomes possible. 
Community risk mapping
Risk mapping occurs at every level of the Cuban government.  At the community level, it is performed by people living in the neighbourhood such as the family physician or representatives of mass organizations.  The meticulous, ongoing risk mapping is the mortar in the wall of Cuba's risk reduction.  This annual community-level risk mapping is key to pinpointing particular vulnerabilities of the community.  When the plan is updated, the information from community mapping is used to identify those at risk, transport needs for evacuation, structures that can be used as shelters and expected resource needs. 
Cuban disaster diplomacy
Disaster and medical diplomacy are key components of Cuba's foreign policy. Although activities have often focused on countries with close ties to Cuba, heavy reliance on disaster diplomacy as a pillar of foreign policy is most dramatically demonstrated by its recent collaboration with Venezuela. The relationship also illustrates the frequent overlap of health and disaster diplomacy.  From the 1960s to 1999, relations between Cuba and Venezuela were contentious at best. Subsequently, according to the disaster diplomacy agreement between these two nations, Cuba provides medical and healthcare support to Venezuela. In return, Cuba receives 100,000 barrels per day of discounted oil, which predictions estimate will result in billions of dollars of free oil over the next decade. ,
Future challenges and opportunities in Cuba
In Cuba, modernization of hospitals and other facilities has slowed, health worker salaries have remained low and stagnant and acquisition of equipment and materials is delayed.  From the government's perspective, their investment in medical internationalism is partially covered by Alianza Bolivariana para los Pueblos de Nuestra América (ALBA), the new trade agreement among Venezuela, Bolivia, Nicaragua and Cuba; therefore, examining the medical role of various key players is instructive. With a surplus of medical personnel, the use of trained medical cadres is an enormously successful economic policy.  However, the Cuban economy depends heavily on relations with Bolivia and on ALBA. 
The unsustainable conventional healthcare system
A healthcare system that has until now been a special priority can no longer be maintained. Certainly, Cuban health expertise has made medical diplomacy an important aspect of foreign policy.  However, many family physicians' offices in Havana are now closed. ,, Cubans occasionally complain about their family physicians participating in an international mission or having to walk farther to the local consultorio because so many medical personnel are abroad; approximately 20% of Cuban physicians are working abroad.  Therefore, Cubans have had to adjust to a new era of domestic healthcare provision. 
Cuba has invested excess capital to enhance primary healthcare. Consequently, continued and expanded social welfare costs, amounting to 40% of state spending, have applied excessive pressure on the Cuban economy.  The pension system is unsustainable because of the high uncovered rates. Therefore, the amount does not reflect reality. Life does not hold the benefit of value.  Further, an aging population and lack of housing are becoming serious problems.  The equality, universal principles and socialist welfare state that have developed with Cuban socialism can no longer provide enough life support to people; social security is in a pre-crisis state. 
As of 2013, 12.3% of Cubans are 65 years or older (25.0% of Japanese). , This aging population will greatly burden health services, especially those addressing chronic conditions and rehabilitation.  Cubans are beginning to face the same health problems faced by the developed world, with increasing rates of coronary disease, obesity and an aging population.  Controlling such chronic conditions requires both medical care and long-term prevention strategies, particularly in a society with limited resources. 
Vulnerability of the Cuban economy
The most current and notable challenge in Cuba is economic vulnerability. The Cuban economy has always been supported by unbalanced inflows from abroad. Economic growth is essential for sustained improvement of life and stability nationwide.  The Cuban economic base is typical of less developed countries; economic independence is impossible. When other countries evaluate the versatility of the Cuban model, fully recognizing the vulnerability of the Cuban economy is necessary. 
| Current Disaster Management and Challenges in Japan|| |
Regional disaster risk reduction plan
In Japan, earthquakes occur frequently and typhoons too occur annually. However, no efforts have been made to form a systematic disaster management plan so that the country, prefectures, cities, villages and districts cooperate.  The regional disaster risk reduction (DRR) plan enumerates necessary measures for damage assumption results and does not perform the requirements as an enforcement plan.  Unlike Cuba, community resident organizations are not members of the DRR conference and the focus is not on the community. 
| Current Disaster Management in Japan and its Focus on Emergency Response|| |
Current disaster management in Japan does not focus on prevention measures for disaster; instead, it is atypically centered on emergency response. In the regional DRR plan, 70% of the content is occupied by emergency response.  Therefore, categorizing Japanese disaster management into HFA, as shown in [Table 4], is difficult. Japanese citizens are taught that emergency response equals disaster management [Figure 2]. The basic content of the regional DRR plan comprises a damage assumption and hazard map. In fact, a detailed hazard map is made with each level in Cuba. 
|Figure 2: HFA priority actions and shift of disaster management categorization in Japan|
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|Table 4: Categorization of Cuban disaster management in hyogo framework for action|
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| Towards a Sustainable and Resilient Future Disaster Management Plan in Japan|| |
First, a review of the regional DRR plan and development of implementation plans with set goals are urgently needed. Second, a detailed hazard map for safe land use and dangerous district measures is required. Third, promoting the creation of a community-based DRR plan is necessary. In addition, including a representative of the community organization in the DRR council of the local government is essential.  For the DRR strategy, the local government should emphasize on community.  Therefore, the local government can create a hazard map and community DRR plan for each district in cooperation with community organizations. This should provide support to community residents and organizations so they can promote the development of a disaster-resilient community by their own initiative. 
Providers of medical services should not be limited to experts; promoting the utilization of medical treatment methods in the region and the treatment of people living mutually in the community is necessary.  A conversion from 'global healthcare' to 'local healthcare' is required for a sustainable healthcare system.  If the sustainable healthcare system is reconsidered, changes in medical perspectives are necessary. ,
Officials and resident leaders responsible for DRR management in local regions should modify disaster management categorization in Japan to a prevention strategy similar to the Cuban disaster management plan and HFA priority actions [Table 4] and [Figure 2]. ,, Therefore, in the future, comparison of the healthcare systems and categorization of EWS and disaster management in HFA is necessary for both Cuba and Japan.
| Conclusion|| |
The Cuban community-based healthcare and disaster management system is exemplary. Japan could learn many lessons from Cuba. Though the country frequently experiences major hurricanes, very few deaths occur. Thus, Cuba has excellent DRR management. However, Cuba faces many challenges; therefore, its system can only serve as a partial reference. Cuban disaster management involves preventive principles, education and community resilience. Similarly, Japanese disaster management should shift focus from emergency response to preventive strategies similar to those in the Cuban disaster management plan and HFA. Moving towards more sustainable and resilient disaster management in Japan is essential.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]