Combating smoking in Cuba

Summary

The aim of this paper is to determine the prevalence of smoking among adults and youths in Cuba, its impact on health the legislation in place to combat it. Worldwide, smoking causes 90% of all lung cancer cases and is also responsible for the majority of oral, pharyngeal, oesophageal and bladder cancers. In addition to this, smoking is a major risk factor for chronic airway diseases, cardiovascular diseases problems during pregnancy. Smoking has long been an integral part of Cuban culture with a history dating back hundreds of years. The Cuban cigar and cigarette are icons in Cuba, with tobacco being one of the country's biggest exports. However, its detrimental impact on health is widely documented and, despite Cuba's remarkable health care system, rates of smoking related diseases are considerable. Until very recently, government tobacco control policies have not been stringently enforced. This student essay argues that Cuba is finally making a concerted effort to stem the tide of smoking-related morbidity and mortality.

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• As much as 90% of lung cancer cases (including the trachea and bronchi)
• "Almost all cases" of laryngeal cancer (in synergy with alcohol)
• 60-90% of oral cavity pharyngeal cancers
• 75% of oesophageal cancers

The report found direct causal links between smoking and pancreatic, stomach, bladder and cervical cancer. The WHO estimates that smoking causes 30% of pancreatic cervical cancers and between 40-70% of bladder cancers (10). In addition to the various forms of cancer mentioned above, smoking also causes the vast majority of chronic obstructive pulmonary disease. Furthermore, it is recognised as a major risk factor for coronary heart disease (which includes myocardial infarctions angina), cerebrovascular events (strokes) and problems with regards to pregnancy (for example low birth weight of babies).

Quitting smoking, at any age, is beneficial to health. Studies have shown reductions in mortality after quitting and reductions in the risk of developing all of the diseases mentioned above (11).

Prevalence of smoking

Cuban adults can claim to be among the most prolific smokers in the world: 37.2% of Cuban adults smoke. Argentina aside (40.4%), this figure is higher than any other in the region of the Americas. There are only a handful of countries where people smoke more, such as Guinea, Namibia Mongolia, where rates are nearer (and sometimes surpassing) 50% (12).

Nearly half of Cuban adult males smoke (48%) - more than any other nation in the Americas. Cuban women cannot quite replicate this figure - 26.3% of them smoke. Although still considerable, more women smoke in Brazil, Argentina Venezuela (29.3%, 34% 39.2% respectively). In men, it seems education has a role - a study in Havana found that the higher the education level of a man, the less likely he was to be a smoker. This association was not found in women (13).

To put these figures into perspective, in the UK and USA, approximately a quarter of adults, male and female, smoke. In many countries, smoking rates are lower than 10%.

While it is clear that a large number of Cubans use tobacco products, significantly more did in the past. In the early 1970s, over 53% of Cuban adults smoked, some 16% percent more than today. This is born out by the annual cigarette consumption statistics. The average Cuban consumed 2690 cigarettes per year in the 1970s, 2280 in the 1990s and down to 1343 in 2005 (14). This figure is now higher in the UK USA, despite the fact that a lower proportion of adults smoke.

Cuban youths however, smoke much less than their American counterparts. The Global Youth Tobacco Survey (GYTS) aims to quantify the number of smokers who are aged 13-15 globally. It is a collaborative effort between the World Health Organisation, the Centres for Disease Control Prevention, the United Nations Children's Fund and the World Bank.

According to the GYTS, far fewer Cuban youths light up regularly (under 20%) than in many other countries in the Americas. By contrast, in Venezuela, Chile Bolivia more than 30% of youths smoke 26% in the USA.

The survey also attempts to illustrate future smoking trends, by this measure at least, it seems that the prevalence of smoking will decline in Cuba. 11.6% of Cubans in the survey intend to start smoking in the coming years, as opposed to 25% of their counterparts in Argentina, 28% in Chile 31.4% in Peru. Although this is encouraging, there is evidence to suggest that Cubans are most likely to start smoking at the age of 17.

With regards to passive smoking, Cuba does not fair so well: 67.6% of youths are exposed to second-hand smoke at home. This is more than any other country in the world, testament to the high level of tobacco use by Cuban adults. In many other American countries, that proportion is less than 30% (15).

Running with the theme of setting bad examples, the latest available data shows that approximately 25% of physicians in Cuba smoke. This is good compared to some other countries in the region - in Bolivia and Chile the figure is more than 35% (16) (17). When compared with developed countries however, 25% looks decidedly less than impressive: 3.3% of physicians smoke in the US, 13% in the UK (admittedly using data from the 1980s) (18) (19).

Prevalence of smoking related cancers Smoking is acknowledged as a major risk factor for several types of disease. However, the association between tobacco and cancers of the mouth, throat, lung and bladder are the most marked.

Lung Cancer

Cancers are the second leading cause of death in Cuba. Those of the trachea, lung and bronchi outnumber the next most common forms of cancer by two to one. The number of deaths due to cancers of the lung, trachea and bronchus have been rising for many years. In 1970, 1912 people died of lung cancer and in 1980, this number had risen to 2409. By 2005 however, this figure was now 4433. The overall crude mortality rate nearly doubled from 22.3 deaths in 1980 to 39.4 in 2006 (20).

This can be explained by the fact that lung cancer rates reflect chronic smoking levels in the past, not current smoking, particularly among adolescents. Lung cancer develops over many years of tobacco use - it is much less likely that somebody who started smoking in 1950 would have the disease by 1970 than by 2006. The age adjusted mortality rate for lung cancer in Cuba - 29.5 deaths per 100,000 people in 2002 - is one of the highest in the Americas. This is lower only than Canada, USA and Uruguay.

The mortality rate in Cuban men is very similar to that of the USA and Canada. The rate in women, however, is appreciably lower than their North American counterparts - this can be attributed to the lower proportion of female smokers in the country.

Other Cancers

Cancers of the mouth, oesophagus and larynx have become more common in Cuba. These cancers are similar to lung cancer in the fact that they are related to smoking (although larynx aside, alcohol is also a major risk factor) and that many years of the habit is required for them to develop (21) (22). 82% of oral cancers in Cuba can be attributed to smoking. Rates for all of these cancers are among the highest in Latin America, often higher than those of the USA and Canada. A possible reason for laryngeal cancer rates being so much higher in Cuba is the greater use of cigars and black tobacco (23).

Treatment of smoking related diseases

Cancer control activities and their systematic evaluation started in Cuba in 1964 with the foundation of the National Cancer Registry (NCR). The NCR is a nation-wide cancer registry and was one of the first in Latin America. It receives collates information of all new cancer cases diagnosed in Cuba and is thus pivotal for coordinating cancer control.

In terms of treatment, cancer patients are managed by specialists in the field - oncologists and anaesthesiologists. Many of the country's hospitals have had pain clinics since the 1980s and in 1992 a National Pain Management Palliative Care Program (PADCP) was created, based on WHO guidelines. The PADCP provides services to terminal patients and their families in their own communities homes in the provinces most affected by cancer (24) (25).

In 2007, the National Cancer Control Unit was created in order to map and coordinate all aspects of cancer control in the country under one agency, thereby better utilising Cuba's resources. It is in its infancy stages, its task is huge. The unit will be involved in development of new initiatives, for example country-wide health screening programmes for lung cancer (26).

Quality of care and cancer research

The vast infrastructural human resources of the health system mean that Cuba is able to offer a high quality of care to its cancer patients.

The Centre for Research on Minority Health of the University of Texas conducted a study in 2007 that compared the quality of cancer care in Argentina, Brazil, Cuba, Mexico and Peru by means of a survey. Health staff involved in cancer treatment were asked about their opinions on the quality of, access to and affordability of cancer treatment in their respective countries. In all three categories, Cuban responses were consistently the most favourable. The survey used this information to describe each countries cancer care as either 'good', 'fair' or 'poor' and rate them out of 5 in terms of 'appropriateness' with respect to the three assessed criteria. Cuba was the sole country to receive a 'good' rating overall and the only country to receive more than 3 out of 5 for each criterion (24).

Another study, conducted by the National Cancer Registry itself, assessed the quality of care in more objective terms. It did this by comparing mortality rates of various cancers in Cuba to those of the USA. Five-year survival rates for cancers of the colon, prostate, cervix and breast were much lower in Cuba. For smoking related cancers however - those of the mouth, oesophagus, pharynx, larynx and lung - survival rates were almost the same as in the USA (25).

Cuba has been described as a world leader in terms of cancer research and has acquired a reputation for developing effective medicines. The Centre for Molecular Immunology (CIM) opened as a research centre for the development of cancer immunotherapy in 1994. Many medicines developed there are now being used or trialled in developed countries, including those for lung cancer. Cuba's expertise in terms of biotechnology has been economically successful; fees from foreign patients and the export of medicines and health equipment are expected to make it rapidly overtake tourism as the country's primary foreign exchange earner (27).

Treatment of cardiovascular disease

The health system in Cuba is adept at managing cardiovascular disease. All major classes of drugs for high blood pressure are produced locally and the levels of treatment control of hypertension are the highest reported for any country (28) (29) (30). Treatment of myocardial infarction (MI or heart attack) is of an international standard, with pre-hospital treatment units operating in most municipalities. Locally manufactured recombinant streptokinase (used to break up the clots that cause MIs) is used routinely promptly and the 'door-to-needle time' is 30 minutes or less for over 90% of all patients with ST elevation (a marker of a more severe type of heart attack) on the electrocardiogram (31).

Shortage of supplies the United States embargo

While Cuba is rich in human capital and has the capacity to develop life saving treatments, large amounts of health equipment life saving cancer medicines must be sourced from abroad. These include chemotherapeutic drugs and radiation machines that are used in treatment. The situation is the same with regards to X-ray machines and CT MRI scanners that are required for diagnosis prognosis.

Much of the above equipment is in short supply. For some, this leads to delays in treatment, which worsens prognosis. Others may receive no treatment at all. While much of this shortage can be attributed to a lack of funds, the US embargo that bans any commercial activity between itself Cuba has had a profound effect.

A large proportion of drugs used in chemotherapy are currently produced in the USA and they are often comparatively cheap. As a result of the embargo, these drugs must be sourced from further afield. This drives up costs, not least because shipping from the USA would be considerably cheaper than from Europe, for example. Shortages of these drugs are now so critical that up to 80% of patients that need them for palliative reasons in some areas cannot be offered them - and only those with a realistic chance of survival have that opportunity.

This situation extends to equipment. Radiation diagnostic machines cannot be obtained from the USA. They are concordantly sourced from other countries. Many manufacturers of these machines are, however, subsidiaries of US companies and the embargo applies here too. Much diagnostic equipment in Cuba sourced from Europe or Japan has US-made components. Maintenance of this equipment is therefore extremely difficult, as certain spare parts cannot be purchased. The commercial blockade between the two countries has been broken before, however, but not of benefit to Cuba. The CIM-developed chemotherapeutic drug Nimotuzumab has been shown to be effective in treating a wide range of cancers. Parents of cancer sufferers in the USA heard of this and requested to use the drug. Through a lengthy bureaucratic process, drugs were provided to the US on grounds of 'compassionate use' (32).

Despite the unique restrictive economic conditions to which it is exposed, the fact that Cuba runs successful cancer treatment programmes, the like of which are absent in the vast majority of the developing world, is a huge achievement.

Tobacco Control

The main solution to the considerable burden of disease caused by tobacco is to reduce smoking through Tobacco Control. In nations where smoking has declined, control programmes consisting of a number of the following measures have shown to be effective:

• Mass media health education programmes
• Restrictions on smoking in public places
• Bans on all forms of tobacco advertising promotion
• Clear health warnings on tobacco products
• Regular increases in tobacco taxation
• Helping smokers quit
• The incorporation of gender-specific measures
• The regular monitoring of tobacco use prevention policies

Although impossible to accurately gauge the impact of a specific measure - a population is rarely subjected to just one - there is evidence that they work synergistically (33).

In recognition of the global health impact of tobacco, the WHO launched the Tobacco Free Initiative and developed the world's first global tobacco control treaty: the Framework Convention on Tobacco Control (FCTC) which was ratified in February 2005. The FCTC is legally binding according to international law in all its signatory countries. It establishes specific regulations, obligations and time scales for the implementation of a wide range of tobacco control policies, including those mentioned above. An example of this is that all parties are required to enact comprehensive bans on tobacco advertising, promotion sponsorship within 5 years of signing the treaty. In short, the FCTC has mobilised countries to actively undertake tobacco control (34).

Mass media health education programmes that utilize television, radio, magazines and newspapers are important as they are valuable tools for making people aware of the risks of certain behaviours. For someone unaware of them, the perceived benefits of smoking (i.e. pleasure) will outweigh those risks.

In line with education concerning the negative impacts of smoking, eliminating the promotion and advertisement of tobacco is paramount. Its correlation with increases in the initiation of smoking has been proven. Evidence demonstrates that only complete bans on all forms of advertising and promotion are effective, particularly as if only one form is prohibited, another permitted form will pick up the tobacco industry's baton. Countries with higher numbers of young smokers are those where adolescents are more exposed to direct tobacco publicity. Restrictions on smoking in public work places directly protect non-smokers from the harmful effects of tobacco smoke. In terms of economic benefits, they are also one of the most effective measures for reducing tobacco use (33).

Conspicuous health warnings printed on cigarette packs provide crucial information to smokers are very effective in communicating health risks. Studies in Brazil and Canada have demonstrated that they often motivate smokers to attempt quitting or reduce the amount they do consume.

The relative affordability of tobacco products in a country is often a major factor that determines their purchase. Decreasing affordability through regular tax increases has proved a useful tool in reducing cigarette consumption, not least in Jamaica where the extra revenue has been channelled towards the health system (35) (36). The World Bank considers this the most useful anti-tobacco policy, as high prices means fewer adolescents can afford to start smoking and more adults are forced to quit. More importantly, tax increases have been shown to work in countries of all levels of income. On average, a 10% price hike can reduce demand for cigarettes by as much as 8 percent in low middle-income countries (33).

The economics of tobacco control

The tobacco industry often argues that smoking benefits the economy. It is claimed that if control measures are introduced, there would be permanent job losses, higher taxes on tobacco would result in lower government revenues and higher prices would cause an increase in the illegal tobacco trade. While governments generally recognise the health implications, several, particularly those of tobacco-producing nations, have been disinclined to implement measures which they fear may have adverse economic consequences.

However, as the WHO and World Bank explain, money not spent on tobacco can be used for basic human needs such as food, shelter, education, health care and other goods and services, thereby generating more jobs in other sectors. Thus falling tobacco demand does not lead to falls in employment- research has shown that some countries have benefited from net employment gains. Tobacco has the ability to worsen poverty for smokers and their families since tobacco users are at much higher risk of falling ill and dying prematurely - this deprives families of income and imposes additional costs for health care.

Is tobacco control cost effective?

The World Bank's report on the economics of tobacco concluded that control is highly cost effective for low and middle-income countries. Tax increases, in terms of expenditure for each life saved, have been shown to have similar costs to childhood immunisation programmes - public health tools widely used by many governments.

In addition to health consequences, smokers are a financial burden on non-smokers. In high-income countries, smoking-related healthcare accounts for between 6 and15 percent of all annual healthcare costs. Smokers' annual lifetime healthcare costs have regularly been shown to exceed those of non-smokers. Thus, in healthcare systems funded by taxation, the cost to non-smokers is easy to see. In developing countries, where the largest proportion of the worlds smokers live, that burden is set to increase in the future.

Anti-smoking policies in Cuba

Tobacco Control Legislation

The sheer volume of ill health as a result of tobacco in Cuba has not been overlooked by the Cuban authorities. That age old symbol of Cuba itself - an image of Castro puffing on a cigar - is somewhat misleading. He actually quit smoking in 1986 and is reported to have advised a group of students that the best thing to do with a box of cigars "is to give them to your enemy" (37). Whether Messrs Bush, Clinton Reagan et al received regular gifts 'courtesy of Fidel' has proved difficult to ascertain, however.

There are currently many policies initiatives aimed at curbing the amount of smoking in Cuba, ranging from smoking bans in public places to health education on the subject. Cuba has also signed up to the World Health Organisation's Framework Convention on Tobacco Control (38).

A formal tobacco control program operates within the Ministry of Health. Current tobacco control legislation is comprehensive, on paper and is comparable with some of the strictest regulations globally. The WHO maintains that Cuba, along with Brazil and Canada, are the only nations in the Americas to have "restrictions sufficiently broad to reduce consumption" (5). They include:

• Bans on all forms of tobacco advertising, on radio, television, in print, outdoors, at point of sale and even indirect promotion in cinema
• Prohibtion of sales to minors
• Prohibiton of sales in health centres, schools and other centres for youth and children
• Bans on smoking in public places, including workplaces, schools, theatres, libraries, museums and health facilities (for staff, patients and visitors), creating smoke-free areas in restaurants
• Instructions for health staff to 'take advantage of all opportunities to provide information concerning the harmful affects of tobacco'
• Public health education concerning the harmful effects of tobacco to be regularly printed in magazines or newspapers played on the radio or television
• Current legislation also dictates that Cigarette packets must carry health warnings (39) (40).

Cuba does not, however, offer much in the way of helping people quit smoking. Nicotine replacement therapy and bupropion are not available. Smokers wishing to stop can either call a toll free line or visit a health facility for advice. Cuban scientists have also reportedly been developing a safer form of tobacco. Designated IT-2004, it is claimed to have fewer adverse affects on health is not as addictive (41). These claims have not been verified yet.

Enforcement of legislation

Impressive though the legislation and policy supporting the anti-smoking campaign are, they are inconsequential without enforcement. The WHO rates the enforcement of smoking regulations in this area as 5 out 10, lower than many countries in the Americas. Some of the restrictions have existed since the early 1980s and all of them have been in place as of 2002 (40). Despite this, it appears that enforcement only began in earnest after 2005, when the Cuban government published regulations in the Gaceta Oficial. None of these regulations were new at the time (42).

Up until the renewal of the regulations in 2005, smoking in most of the aforementioned places was commonplace. News reports from the Daily Mail, BBC and US news agencies at the time described how it was still "common to find people smoking in hospitals, elevators even crowded buses" despite previous attempts to curb the habit. Few smoke free areas in restaurants had been put in place and descriptions of foreign tourists lighting up liberally in establishments being frequent (43) (44).

Since then, however, the application of the regulations appears to have become stricter. Just as reports of the law being flouted prior to 2005 were common, those of their enforcement have become more prevalent. Health staff and office workers are now at least asked to leave an establishment and at the most they are fined by health and epidemiology inspectors. Hotel guests and restaurant patrons are now asked to light up either in designated smoke free areas or outside. 'Do not smoke' signs are now more common and appear to be obeyed more regularly. They appear in many public places, from restaurants to barber shops (45). These accounts must be taken into context, however - the restrictions were largely ineffectual before and articles still surfaced that said nothing had changed in many areas (46).

The law prohibiting sales of tobacco to minors has been in place since 1981. Up until 2005 at least, it seems as though it was completely overlooked. There are numerous accounts of seeing several young children being sold smoking cigarettes and the frequent revelation that they had been sent to buy them for their parents (47). Although these figures are likely to have reduced since 2005, the Global Youth Tobacco Survey showed that 17.6% of Cubans aged 13-15 smoked in 2002. Of these, 41.8% bought tobacco from a store and 88% of them said they had never been rejected by store clerks (15).

The same survey showed that the advertising bans (in existence since 2001) were also largely ignored: 67.4% of youths had seen pro-cigarette advertisements on billboards in the past 30 days, 63.6% in newspapers or magazines; 13.5% had an object with a cigarette brand logo; and 7.5% had been subject to perhaps the most direct form of advertising possible - they were offered free cigarettes by a tobacco company representative. More encouragingly however, 92.4% had seen or heard anti smoking messages in print, on television or radio in the past 30 days. Post 2005 reports of advertising billboards and the like being ripped down have surfaced, as do reports that much of it still remains (47).

Somewhat interestingly, the announcement in 2005 forbade the selling of cigarettes through the medium of vending machines; some articles are unsure as to whether these have actually ever existed in Cuba. Cigarette packs are labelled with health messages that cover 30% of the outer packaging (47). The law mandates 5 specific health warnings for these packs:

"Smoking produces serious health risks"

"Smoking causes cancer"

"Smoking causes irreparable damage to the heart"

"Smoking subtracts years of life"

"Stopping smoking is a very sensible choice"

Although informative, these messages do not quite have the same impact as those of other countries. "Stopping smoking is a very sensible choice" seems more like a polite suggestion than a warning. Compare this with "Smoking can cause a slow painful death" (which is accompanied by a picture of a hospitalised patient) in the UK (48). Nevertheless, many countries in the Americas (including the USA) do not have any requirements for cigarette packages and some do not stipulate the percentage that should be covered. Others, such as Brazil, Canada, Jamaica and Venezuela, mandate over 10 health messages for packs, for a larger percentage to be covered by health warnings.

Cigarette prices and attitudes towards the smoking bans

Modern tobacco control policy recommendations are based on the reduction of demand through decreasing the relative affordability of products, for example increasing taxation. Considering the wide reaching nature of other tobacco control regulations in Cuba, increasing the price of cigarettes seems to be an alien concept.

Cuban cigarettes are some of the cheapest in the world. Rather than taxing them, a large proportion of cigarettes have actually been subsidized for many years. People born before 1955 are currently rationed three packets of (very low quality) cigarettes per month, at a staggeringly low price - equivalent to 7 US cents each - a policy that shows no signs of changing. Even cigarettes that do not form part of the ration (and are thus available to everyone) are extremely cheap. The non-subsidised cost of the same cigarettes is roughly $0.27, on which the excise is 22%. Equivalent cigarettes in Brazil Argentina cost $0.80 $1.10, with excise rates of 32% 61% respectively. Those of the export quality variety, for example the Populares brand are sold at approximately $0.60. The most expensive, Romeo y Julieta, go for roughly $1.50 per pack (47).

Why then, given the fact that Cuban authorities want to reduce smoking in the country, are cigarettes sold so cheaply?

"We aren't exempt from contradictions." This was the response of Francisco Safora, of Cuba's Institute for Hygiene Epidemiology, when asked about the subject (6). Pedro de la Hoz, a Cuban journalist called the situation where people are told not to smoke sold cheap cigarettes "schizophrenic" (49).

Given the history of tobacco in Cuba, it is no surprise to see that it is heavily ingrained in the country's culture. It is famed for being a tobacco-producing nation and Cubans are proud of that fact. A study in 2005 that interviewed young adults from Latin America suggested as much: "for Cubans, smoking is part of the culture, lots of people do it. It is kind of a trademark" (50).

News organisations reported that many were scathing of the newly enforced smoking regulations in 2005. More youngsters, however, tended to agree with the newly enforced regulations. The GYTS polled Cuban youths in Havana regarding restrictions. The vast majority of them (80.5%) stated that they would like to see smoking banned from public places. According to the survey, this is almost the same exact proportion of non-smoking youths (15).

Conclusion

The impact that tobacco use has on health in Cuba is considerable. The proportion of smokers in the country is one of the highest in the world, as is the incidence of tobacco related disease.

Cuba's health infrastructure is very sophisticated and is at the forefront of medical technology knowledge in many areas. It has managed to create a system with relatively meagre resources that is adept at dealing with the multifarious demands of treating often terminal diseases such as lung cancer. The fact that it has done this with the added financial pressures created by the United States embargo is nothing short of remarkable. Nevertheless, prevention remains the best strategy to combat smoking related disease.

While it is true that the dangers of smoking have been known for many years now, it has taken a considerable amount of time for Cuba to respond to the threat. This is not, it must be said a Cuba specific problem - smoking bans have only been introduced within the last year in the British Isles for example. In terms of anti-smoking legislation, Cuba can claim to have been more advanced than much of the developed world for some time.

Legislation, however, is worth nothing without enforcement. This appears to have been the situation in Cuba for more than two decades. Bans on tobacco advertising, bans on cigarette sales to minors and restrictions on smoking in public places have all been largely ignored until very recently: laws in name only.

Perhaps the biggest issue with regards to the high levels of smoking in the country is the incredibly low price of tobacco products. There is plenty of evidence from many countries to suggest that tax increases deter people from smoking without adverse economic effects. To date, whether for cultural or economic reasons, this is a policy that Cuba has chosen to steer clear of.

The prevalence of smoking, however, is going in the right direction. Fewer Cubans smoke now than at any time before. Health education media campaigns also seem to be having a positive affect on the Cuban youth. It seems realistic to hope that there will be fewer smokers therefore a decrease in related diseases in the future. It appears that Cuba has woken up to the dangers of tobacco is finally making a concerted effort to stem the tide of smoking related morbidity mortality.


Rishabh Singh is a third year student at King's College London School of Medicine. This essay was written as a research assignment for the special study module 'Exploring Cuban Health Care'. Email Rishabh.singh@kcl.ac.uk

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Notes

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Copyright
Copyright for this work is held jointly between Rishahb Singh and the International Journal of Cuban Studies under a Creative Commons Attribution-NonCommercial-No Derivative 3.0 Licence
IJCS Volume 1 Issue 1 June 2008