Letter to the Editor

Regarding the article "Violence as a health problem. Review from the Cuban reality"

Yamila Ramos Rangel^{1  *} 
http://orcid.org/0000-0001-6749-7523

Laura López Angulo¹ 
http://orcid.org/0000-0002-8699-5533

¹Universidad de Ciencias Médicas de Cienfuegos, Cienfuegos, Cuba.

Mr. Editor:

"Violence as a health problem. Review from the Cuban reality", ¹ is a review article published in the Gaceta Médica Espirituana journal, 22(1) 2020, it enquires into essential aspects of violence treatment as a health problem, as well as the role of health professionals regarding its care; and concludes with related-pertinent evaluations.

Violence as a health problem is among the priorities of public health due to its magnitude and the disastrous consequences it causes to health; ¹ so it is positive to present this position to the scientific community with updated data, like the one offered in the aforementioned article. ¹

In the treatment of this phenomenon it is important to consider that the WHO and the PAHO identify violence as a health problem, at the same time point out the possibility of reducing it through promotional preventive actions.

The presence of violence as a risk indicator in the onset of multiple diseases, which can even lead to loss of life, is testified in the article; thus the urgent need to train health professionals in the screening, care and referral of this menace.

It is a conceptual theoretical principle to look at violence not as an unsolvable problem, nor as an intrinsic condition to human nature. It is necessary to progress in the analysis of the factors that lead to this complex problem and the possible responses (not at all spontaneous) for its solution.

It has been very opportune in the article to contrast, through research, the presence of violence in its different manifestations and the "gaps" in the health employees training to face this problem.

It shows that violence is a current phenomenon in individual, family and community daily life, which can be expressed both explicitly and subtly. It is revealed in real and virtual spaces, which damages the health of the human being.

According to the role of health professionals in Primary Health Care as described in their article, ¹ the evidence of studies presented by the authors is very useful, pointing out the limitations of the Basic Health Team in their performance by neglecting occasionally the appropriate screening, registration and follow-up of patients who suffer violence and ignoring, or not recognizing, the main warning signs. In this sense, data that could also support what is stated by these authors, is the fact that in the National Health Statistical Yearbook ² of 2018, violence is not recorded in any of its typologies and manifestations and the charge sheets of medical professionals in the province of Cienfuegos do not diagnose cases of violence in any age group.

In view of what has been stated to in previous paragraphs, it would also be necessary to question: how is this phenomenon of violence presented in the Medical Sciences students, if it is known that their actions as future professionals include its treatment? In an exploratory study conducted at the Cienfuegos University of Medical Sciences, ³ it was found that 24 % of medical students in their first years perceive there is violence in existing relationships in the institution and have a low knowledge on the typology of its expressions.

knowledge on the existence of violence in the Medical Sciences students, and its explanatory deepening, is still insipient. The presence of violence in the life of these future professionals, in any of its manifestations and not being able to identify, has serious repercussions on the future graduate both personally and professionally. It is important to bear in mind that the mere fact of being a student or a health professional does not prevent these people from being victims of violence or perpetrators of mistreatment in their family, work and community spaces, unable to identify the violence cycle they are themselves and eliminate it. That is why it is necessary to continue researching this population, which allows for corrective actions supported by science. It is impossible for a health professional who survives, both as a perpetrator and/or as a victim of violence, to attend to patients and population, in a general sense, in a situation of violence and to develop sustainable and efficient actions and services.

Cuba applies a non-tolerance policy to crimes of violence in any of its modalities, established in a set of actions and measures, although their implementation they can still be perfected.

Cuban National Health System, due to the state and social nature of medicine, accessibility, universal coverage, free health services and the active participation of the population in several programs, has contributed to raising the health indicators of the entire population. The health system is constantly being improved with the organization and care of its services, programs and structure, improving all care levels of quality services seen as a system.

Improvements to the Family Doctor and Nurse Program have been made, improving the plans, curricula and teaching literature of medical specialties, where the gender approach has been incorporated. Violence topic has been included in the Medicine career and in postgraduate course of the MGI specialty.

The National Group for Prevention and Care of Domestic Violence, of which Public Health is a member, develops training, educational-preventive, care, research, legislation, and dissemination actions to address this menace, as part of the agreements of the National Action Plan for Follow-up to the Beijing Conference of 1997. ⁴

Despite the fact the Cuban health system has contributed to improving comprehensive care for people, also is active in confronting all forms of violence and is preparing its professionals, this issue is still uncertain, as the authors of the article state. ¹ Although it is a complex phenomenon that cannot be treated with superficial solutions, at present in the country, the health system, with its personnel and health institutions is in a position to modify some of the professionals’ actions in this matter. An alternative, as the authors conclude, lies in identifying the learning needs of health personnel and making effective and feasible training processes.

In response to this call and to contribute to the health professionals´ training to face this health problem, in the province of Cienfuegos, a team of researchers from the University of Medical Sciences prepared a manual to help women victims of intimate violence ⁵ and a guide for psychological orientation and assistance aimed at professionals who provide telephone assistance related to gender violence. The main motivation in the elaboration of this manual was to offer useful, feasible, pertinent, efficient and effective procedures targeted to all sensible people with the goal of improving subjective well-being, reducing the chronification and escalation of the damage, increasing healthy life in those women having a violence situation. This resource shows procedures, resources, multimodal interventional techniques and care guidelines; it has solved examples and responds to the need of providing information.

The orientation and assistance guide was elaborated in the emerging situation of Covid-19 in response to the demand of the country's top management and the Minsap to activate the 103 Line, called CONVIDA 2020; this has been improved for the opening of an online service that would attend people in situations of gender violence in post-Covid-19 times, in view of the demand increase for attention due to gender violence registered. The guide responds to the need to establish guidelines for individualized care and to obtain experiences of good practices in care and coordination in the care process for survivors of gender-based violence.

On the way to the eradication of violence, there will be many questions and requirements for precision in the theoretical and practical analysis of the possibilities of its treatment. This letter, which echoes the article "Violence as a health problem. Review from the Cuban reality", also intends to be an invitation to discuss and examination of the theoretical and methodological elements that make it possible to deal adequately with violence as a health problem. Health professionals are in charge of developing good practices in research, screening, as well as in all preventive, diagnostic and therapeutic actions they conduct.

It is imperative to define and monitor the magnitude of the problem, identify its causes, formulate and test ways of dealing with it, and widely apply proven measures as recommended by the WHO. ⁶

Throughout the centuries, a culture of violence has prevailed in humanity and has permeated all areas of society: "Arma virumque cano" (I sing to arms and men), says Virgil in his work "The Aeneid", reflecting the enthronement in the ideology and imaginary of humanity of a response to life from aggression and from positions of a masculinity expressed through violent behavior. But reality shows that a culture of peace and care is possible, violence is never the solution to problems, nor remain indifferent to its terrible consequences. The scientific community is called upon to continue working on the treatment of the subject with the consequent preparation of professionals to confront and prevent it.

We would like to thank the authors of the article for their work and the journal for the opportunity to present our considerations.

Sincerely,

Yamila Ramos Rangel and Laura Magda López Angulo

REFERENCIAS BIBLIOGRÁFICAS

1. Ferrer Lozano DM, Guevara Díaz EL, Martínez de Ring ME. La violencia como problema de salud. Miradas desde la realidad cubana. Gac Méd Espirit [Internet]. 2020 [citado 30 Jun 2020];22(1):49-59. Disponible en: Disponible en: http://scielo.sld.cu/pdf/gme/v22n1/1608-8921-gme-22-01-49.pdf

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5. López-Angulo L, Fonseca Fernández M, Ramos Rangel Y, Ruiz Hernández M. Manual para la ayuda a mujeres víctimas de violencia íntima. Medisur [Internet]. 2019 [citado 30 Jun 2020];17(6):907-39. Disponible en: Disponible en: http://medisur.sld.cu/index.php/medisur/article/view/4510/3022

6. OPS-OMS. Informe mundial sobre la violencia y la salud [Internet]. Washington, DC: OPS-OMS; 2002. [citado 30 Jun 2020]. Disponible en: Disponible en: http://apps.who.int/iris/bitstream/handle/10665/43431/9275324220_spa.pdf;jsessionid=7E4449E9144684178DF5692A291C4792?sequence=1

Received: August 24, 2021; Accepted: October 12, 2021