4.1 General country information
Located in the Caribbean, Cuba is an archipelago with 11,181, 595 million inhabitants. It covers a surface area of 110,922 km2 which includes the Island of Cuba, Isle of Youth, and more than 1600 islands, islets, and keys . Cuba is characterized by a fantastic diversity of nature, like rolling hills, mountainous areas, savannah, plateaus, and valleys. Political and manageable, Cuba is divided into 16 provinces (Camaguey, Ciego de Avila, Cienfuegos, Ciudad de la Habana, Granma, Guantanamo, Holguin, Las Tunas, Matanzas, Pinar del Rio, Sancti Spiritus, Santiago de Cuba, Villa Clara, Artemisa, Mayabeque, and Special Municipality: Isla de la Juventud). Because of its colonization process by Spain first, and later because of slave trade and migrations from Haiti, Cuba has a diverse genetic heritage. The populations of the east of the country have a greater African origin. While most Cubans appear nearer to European ancestry than African, its people lie on the European-African line, comparably to African-descendants from the USA and Barbados. Native American source populations present a less widespread contribution to the Cuban genetic map .
Spanish being the official language, most of the population speak it as their well-advanced education. However, Cuban Spanish differs from Castilian Spanish spoken in the Iberian Peninsula due to historic migrations from France, Canary Islands and West Africa. Similarly, there is an anglicization phenomenon in Cuban Spanish . Other languages spoken in the country include Haitian Creole, Lucumi, Galician, and Corsican [45–47]. The Roman Catholic Church and Afro-Cuban religions remain prevalent . Cuba’s literacy rate is 99.8%, and health education is part of the obligatory school curriculum . So, all this above description bears upon how to address cultural competence in education.
Since the 1959 Cuban Revolution, the country is marked by continuity of the Communist Party rule. Due to its centralized, state-sponsored economy, Cuba succeeded in building a markedly egalitarian society . Currently, this country is mired in a deep economic crisis, aggravated by the Coronavirus pandemic.
4.2 Health Issues within the Health Care System.
After 1959, the Cuban government built a community-based preventive primary care-oriented health care system for equity in the provision of health supplies, including a powerful pharmaceutical industry being prioritized for domestic needs as well as export to Southern Hemisphere nations. At present, there are 103,835 physicians (21,589 family physicians), 5,319 pharmacists, and 84,977 nurses. In 2019, Cuba's gross domestic product (GDP) amounted to around 103.13 billion US$. GDP decreased -0.22% compared to previous years. Cuba spends 11.7% in the health sector .
Prevention is the first principle of the Cuban health system. Many infectious diseases, such as poliomyelitis, diphtheria, pertussis, and rubella, have been eradicated . An exhaustive testing policy controls HIV/AIDS, the country having the lowest HIV prevalence in the Caribbean (0.1%) in 2007 . The HIV/AIDS program includes wide education effort besides treatment, with anti-retroviral drugs delivered free for all infected patients . Bacterial meningitis showed an incidence of 4.3/100 000 inhabitants from 1998 to 2007 with now a downward trend .
A remarkable aspect of the Cuban Health System is comprehensive general medicine or “Medicina General Integral” (MGI). This structure exercises the principles of the Universal Health Strategy promoted by the World Health Organization (WHO) and the Pan American Health Organization (PAHO) [56, 57]. Its programs are concentrated on preventing individuals from developing diseases and treating them as promptly as possible. Thus, Cuba has been successful in the control of daily health concerns. The integration of MGI into the neighbourhood setting and its connection with hospitals and the Medicines Institutes Research allow for population planning and rapid response to emergencies, for example, during hurricanes . As a result, life expectancy at birth for Cuba was 79.5 years, and infant mortality rates decreased from 4.3 per 1000 live births in 2015 to 3.81 in 2019 [59, 60]. The structure of the Cuban National Health System is shown in figure 1.
A study by Dieci et al.  shows relevant comparison of Cuba with other countries, such as Dominican Republic, Costa Rica, and the U.S related to cardiovascular risk factors: International comparison of levels and education gradients. Hypertension understanding in Cuba is similar with that in Costa Rica, considerably lower than in the Dominican Republic, and substantially higher than in the U.S. For both genders, Cubans have hypercholesterolemia incidence that is lower than in Costa Rica and higher than in the U.S. Cuba, like its fellow citizen, must continue to address the rapidly growing non-communicable disease obligation both within and outside of the health care system.
Studies developed by Franco et al.  to evaluate the associations between population-wide loss and gain in weight with diabetes prevalence, incidence, and mortality, as well as cardiovascular and cancer mortality trends, in Cuba over a 30-year interval shown a stable incidence between 1.5 per 1000 people and 1.8 per 1000 people during the 1980s decade. Similarly, correlations were established between the decrease in body weight and the decrease in diabetes and coronary heart disease, diabetes mortality increased by 49% with the weight rebounding. In addition, a slowing in the rate of decrease in mortality from coronary heart disease was observed. Malignant tumors represented the second cause of death in Cuba (24.4%), in the last 25-year mortality due to Asthma has declined because of preventing therapeutic methods .
The Latin American School of Medical Science (ELAM, Spanish acronym) in Cuba is possibly the world's largest medical school with about 10,000 students, all of whom are newcomers . Many students come from Latin American countries, but the enrollment today also includes 91 Americans who were unable to gain entry to U.S. medical schools. In 2010 the ELAM declared the graduation of 34 students from U.S. This statement obliged the institution to achieve accreditation of the Medical Board of California. These contributions additionally complement the effort of the Cuban pharmaceutical industry, which has long been researching medicines for ignored endemic illnesses in developing countries. However, this work of medical education is not perfect, there are reports about the insufficient skills of South African doctors in Cuba related to identity and cultural readjustments necessities for several returning graduates .
Recently, a study by González et al.  concluded that Cuba considers universal health as one of its most valuable achievements, although it requires a more efficient analysis of reliable and available sources, research, and application of results. Assessing strengths and weaknesses in terms of health economics, updating the sciences, and use of resources and new technologies, as well as deepening lessons learned while facing new challenges. Parallel to that, Cuba has developed a research capacity throughout the health system associated to population mobility, increasing prevalence of chronic diseases, rising health costs, and the need to control communicable diseases in a global context of climate change, among others .
4.3 Cuba´s Pharmacy and pharmaceutical services.
Pharmacy and pharmaceutical services are key elements in the Cuba’s organized system of health care, however, there is a recent scarcity of available products related to pharmaceutical services. This makes it difficult to amply measure the impact of pharmaceutical services within the overall system. Currently, Cuba has 2,144 community drugstores constituting its national public network. In 1994 the National Drug Program was implemented to harmonize methodology and regulations related to medicines across the country. Coordinated by the Centre for the Development of Pharmacoepidemiology (CDP), it created the National Pharmacoepidemiology Network in 1996, whose activities concern drug information, continuing education, and the promotion of drug utilization research to improve medicine uses by its populations. Connected to the 15 provincial health boards, through Provincial Pharmacovigilance Units within the Provincial Department of Pharmacoepidemiology, which in 1976 set up the National Center for Pharmacoepidemiologic Surveillance with the Coordinating Unit for the Pharmacoepidemiologic Surveillance (CUPS) in 1999. These institutions evaluate and process adverse drug reactions, evaluate the risk-benefit balance of marketed drugs to guarantee safety profiles in drug use . Through its membership in the International Centre for Adverse Drug Reaction monitoring in Uppsala, Sweden, Cuba exchanges information about this topic around the world.
The Cuban drug supply chain is managed by a logistics operator to ensure medicines availability according to patients’ needs. This model showed a medium performance level, being a reference of the logistic support to sustain this health system [69, 70]. Figure 2 shows the structure of the Cuban chain medicines logistic. Many Cuban pharmaceutical products and vaccines are commercialized around the world generating hundreds of millions of dollars annually. Cuba produces 67% of its own essential medicines, besides recombinant streptokinase . An agreement between The Roswell Park Cancer Institute of Buffalo, New York, and Cuba’s Center for Molecular Immunology was assigned to produce a lung cancer vaccine .
4.4 Cuban Pharmacy Education and Organization.
Cuba has a totally public pharmacy education system. After five years of undergraduate training, the graduates enter at the practical level as BSc. Pharm. Cuban pharmaceutical programs incorporate chemical, physiology and biological sciences education, in addition to practice at the community, hospital, and industry settings. Several year ago, Social Pharmacy disciplines were introduced to yield pharmacists capable to provide pharmacy patient-centered services. Drug information, patient counselling, drug-related problems, and compliance are studied, proposing a 120-h residency to pharmacy practice . In summary, a pharmacy student takes formal clinical pharmacy and pharmaceutical care education (usually from the fourth to the fifth year). Nonetheless, there is not yet a Cuban standard on pharmaceutical care education, being this training a free choice according to the school of pharmacy and geographical health necessities .
The National Council on Pharmaceutical Education (NCPE) is responsible for quality pharmacy education with establishing standards and guidance according to practice and education evolution. All schools of pharmacy mandatorily assess their educational results against these standards for accreditation objectives. Standards are established in partnership with academics, consultants, regulators, employers, and other stakeholders. In addition, a final evaluation is carried out by the Council for Accreditation of Higher Education to guarantee adherence to standards .
At the community setting Cuban pharmacists deliver counsel about proper pharmaceutical drug uses and over-counter medicines. In addition, they offer advice concerning topics, such as exercise and healthy nutrition. A recent report by Cantluple  summarizes the regularities that characterize the Cuban pharmacy sector: “Cuban pharmacists focused on dispensing essential drugs as they negotiated around many drug shortages in the country, pharmacies were described as virtual drug distribution centers but did not offer widespread healthcare services, and pharmacy services in Cuba in primary care are still primarily dispensing-oriented”.
From anthropology and cultural points of view, food is more than nutrition. Relationships between individuals in society are built around food and eating habits, which shape their identity; perceptions of food are directly related to the nature and organization of societies. One’s food choices reflect a social reality related to our life and perception of the peoples and cultures with which we maintain an identity . A study by Rodríguez-Martín  on eating by Cuban adults compared with those of a developed Western country, Italy, showed Cubans reporting higher scores for food thought suppression with reward responsiveness and restrained eating emerging as significant predictors of between-country differences. Similarly, Cubans demonstrated less tendency to food restrictions and a great predisposition to binge eating; eating behaviors in Cubans could be different from those described in European countries, possibly because of Cuba’s current history of food shortages.
High consumption of calories, fats and sugars is the main characteristic of the Cuban diet, similarly, consuming whole-grain cereals, fruits, and vegetables is scarce. Food is sold in controlled quantities at government-funded prices since the 1960s. Deficit of micronutrients is a phenomenon present with Cuban people, 30-45% of infants aged 6 to 23 months, 25–35% of reproductive-age women, and 24% of pregnant women are affected for iron-deficiency anemia . Disproportionate use of salt in food preparation, minimal intake of dietetic fiber (14g per day), use of reheated oils, minimal consumption of fish, are general characteristics of Cuban eating habits. In short, in Cuba “when you´re hungry, eat what is at your fingertips” .
High alcohol consumption characterizes the social life of the Cubans. A prospective study by Armas  showed that women were current alcohol drinkers, with 15,433 (29%) men and 3054 (5%) women drinking at least weekly among 120,623 participants in 1996-2002. All-cause mortality was positively and continuously associated with weekly alcohol consumption; and cancer, vascular diseases were the main causes of death.
Like other Caribbean islands, Cuba is a safe country. However, the U.S. Department of State’s Travel Advisory Level for Cuba at the date of this report’s publication remains at Level 2: “Exercise Increased Caution”. Travelers must use expanded caution in Cuba caused by discernible and occasionally weakening, damages to members of the U.S. diplomatic community leading to the lessening of embassy staff . Travel to Cuba for people from the states remains banned by statute. The U.S. Department of Treasury’s Office of Foreign Assets Control (OFAC) continues to issue general licenses for twelve categories of travel to Cuba. Persons who meet the regulatory conditions of the general license travel are not required to apply for a special license from OFAC.
4.7 Influence of Spirituality and Traditional Healing on Health.
Since 1959 the health care system maintains national health care as respecting a human right for all the citizenries. The Cuban health system is the lens through which all the nation's problems are measured, including education, housing, and social security . Thus, resources for maintaining health are free, universal, and accessible for all citizens, thus contributing to the identity of the country. The uniqueness of health care to Cuban nationalism’s political and social values remains crucial, though successes in health and medicine do determine national and international aspects of government validity .
The life of Cubans is dominated by intense medicalization and a great biomedical hegemony, both individual and collective. However, outside such conventionalisms, there coexist beliefs and therapeutic practices that are beyond the control of the structured Cuban health system, thus, the evil eye (mal de ojo), and gastrointestinal distress syndrome (empacho) are examples of cultural health beliefs . As a result of its ethnic roots, several syncretic religions, and cults rich in ethnobotanical foundation are practiced in Cuba. Vodún (voodoo), Espiritismo (spiritism), and Santería are the consequence of a largely African cultural legacy that also includes Hispanic and Chinese influences .
By 2005 Cuban government promoted campaigns to resume traditional medicine, and the use of medicinal plants in official therapy, a movement led by the Armed Forces. According to Moret , people came to search for medicinal plants as part of their cultural health practices in a spontaneous way inside the savannas and bushes. Now, because of the commercialization of medicinal plants, individuals go to so-called herbalists for convenience. In these establishments, plants are commercialized with little knowledge about their collection and conservation regulations, all of which, according to the authors, could have future difficulties in the access of individuals to ritual resources and medicinal plants. The value of medicinal plants and the commercialization of ethnobotanical knowledge within Afro-Cuban religious activities has increased, amid deficiencies, inequalities, and social movements based on ethnic and religious identities.