Health Promotion International Advance Access originally published online on December 14, 2007
Health Promotion International 2008 23(1):60-69; doi:10.1093/heapro/dam040
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PERSPECTIVES |
Promoting health in response to global tourism expansion in Cuba
1 Liu Institute for Global Issues, University of British Columbia (UBC), 308-6476 N.W. Marine Drive, Vancouver, BC, Canada V6T 1Z2 2Department of Health Care and Epidemiology, UBC, Canada 3 Institute of Health Promotion Research, UBC, Canada 4Centro de Estudios Turísticos, Universidad Central de las Villas, Santa Clara, Cuba 5Centro de Estudios Demográficos de la Universidad de la Habana (CEDEM), Havana, Cuba
* Corresponding author. E-mail: jerry.spiegel{at}ubc.ca
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SUMMARY |
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The ability of communities to respond to the pressures of globalization is an important determinant of community health. Tourism is a rapidly growing industry and there is an increasing concern about its health impact on local communities. Nonetheless, little research has been conducted to identify potential mitigating measures. We therefore took advantage of the ‘natural experiment’ provided by the expansion of tourism in Cuba, and conducted four focus groups and key informants interviews in each of two coastal communities. Participants expressed concerns about psycho-social impacts as well as occupational and environmental concerns, and both infectious and chronic diseases. A wide array of programs that had been developed to mitigate potential negative were described. Some of the programs were national in scope and others were locally developed. The programs particularly targeted youth as the most vulnerable population at risk of addictions and sexually transmitted infections. Occupational health concerns for workers in the tourism sector were also addressed, with many of the measures implemented protecting tourists as well. The health promotion and various other participatory action initiatives implemented showed a strong commitment to address the impacts of tourism and also contributed to building capacity in the two communities. Although longitudinal studies are needed to assess the sustainability of these programs and to evaluate their long-term impact in protecting health, other communities can learn from the initiatives taken.
Key words: tourism; globalization; community capacity; Cuba
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INTRODUCTION |
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In 2006, an unprecedented 842 million international tourism arrivals were documented worldwide (United Nations World Trade Organization, 2007). This global tourism expansion, boosted by the interplay of global investment, values, tastes and travel made possible by enormous changes in technologies, alongside the eagerness of tropical low-income countries to attract new revenues, has led to the dramatic restructuring of an increasing number of previously isolated coastal communities. Despite the promise of prosperity that is the allure of tourism expansion, there is growing evidence of a risk of negative impacts on the health and wellbeing of local populations (Frechtling, 1997
; Guerrier and Adib, 2000; Apostolopoulos and Sonmez, 2002). As the effects of tourism are felt at a local level, it is valuable to study how communities are responding to such change.
As part of a larger research program to investigate the impacts of globalization on social organization and health, this study was initiated to better understand the impacts of the specific ‘global development’ vector, tourism, in specific community settings (UBC Global Health Research Program, 2004). To this end, we sought to take advantage of the ‘natural experiment’ provided by the expansion of tourism in Cuba. On one hand, despite Cuba's persistence on the ‘margins of globalization’ (Spiegel and Yassi, 2004), over the past 15 years, this Caribbean island has been dramatically re-opened to international tourism arrivals, transforming the industry into one of Cuba's most important economic activities. On the other hand, Cuba's noteworthy achievement in promoting health (Cooper et al., 2006) has been indicative of its independence from the influence of globalization that has lead many other countries to dramatic weakening of local capacity attributable to Structural Adjustment Policies (De Vos, 2005). Consequently, our multi-national team wished to study how Cuban communities are responding to tourism, to protect and promote the health of local communities in order to ultimately inform cross-country comparisons. This article thus examines the community health promotion programs Cuba has developed to help mitigate the negative health effects of tourism development.
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METHODS |
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To consider the community implications of global tourism development, we chose two distinct communities: (i) a community that is at the early stages of impact and (ii) a community with a long history of tourism involvement. In this way, we felt that we could both examine how impacts and response have been experienced retrospectively, as well as how preparation is being conducted with regard to new development. The two communities chosen are situated along Cuba's northern coast. Caibarién is a fishing town of 40 000, connected by a newly constructed causeway of 80 km to the new tourism destination in the North–East Keys of Villa Clara Province, that was still only partially completed (1 in 5 hotels were operating) at the time of the study. Cárdenas is a city with a population of
100 000 that is adjacent to the well-established resort destination of Varadero and is the home for the majority of tourism workers in the region (Figure 1).
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At an early stage of project development, local municipal and health area officials in each community were contacted to develop the plans for conducting the study in a participatory manner.
Eight focus groups were held to gain an understanding of the perceived impacts as well as the activities undertaken to mitigate these impacts. Four focus groups were held in each of the communities, each comprising individuals with distinct relations to tourism development: (i) decision-makers (representing government and city officials); (ii) community (members of community at large, including farmers, workers, teachers); (iii) health-related workers; and (iv) tourism industry workers. The two communities were targeted, 1 month apart; and the four groups in each community met simultaneously for one and a half hours, each with different facilitators. The sessions were recorded and later transcribed for the purpose of outlining and determining the comprehensiveness and relevance of the information. In addition, key informant interviews were held.
After the focus groups and interviews, a descriptive text analysis was prepared and an information matrix developed. On the basis of the information that emerged, health concerns were grouped in the following areas: psycho-social concerns, occupational health, infectious and chronic diseases and societal and environmental concerns. Finally, community meetings were held to report on the findings and identify areas felt to be of particular concern for future policy and action. All focus group participants and key informants were invited to attend these meetings.
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RESULTS |
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Impacts
All focus groups noted that ‘tourism has a physical and psychological impact on people’ with a wide range of health concerns raised in both communities. These are summarized in Table 1.
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Psycho-social impacts
Issues related to psycho-social impacts of tourism were raised more frequently than other impacts in the focus groups in both communities. Interestingly, addictions and obesity were consistently reported less emphatically than changing values, disparity and dysfunctional families.
One participant expressed that tourism ‘allowed us to grow as individuals.’ However, concern was expressed by others that ‘the mentality of the community is changing’, possibly due to the real or perceived inequality in comparison with affluent tourists. In fact, a risk factor for mental health stress was attributed to the ‘prominent [economic] difference between the workers in tourism and the rest of the community.’ As a result, ‘all young people [now claim] they want to work in tourism.’ It was reported that precisely this type of ‘mental stress’ explained the unwelcome behavior of ‘harassment to tourists’ by some young people. No less important were the remarks about family tensions resulting from a perceived reversal of gender roles in families where women have a higher income than men. Finally, perhaps a deeper psycho-social impact of tourism may be reflected in statements such as ‘[now] there is lack of communication between [tourism] workers and others, [including] family and the rest of society’ and ‘[previously] normal families [are becoming] dysfunctional families.’
Occupational health impacts
Several risk factors for occupational health related to tourism were recognized among tourism workers. In both communities, the particular risks identified were increased ‘job-related stress’, risk of ‘pelvic diseases for women’, ‘varicose veins’ and ‘back problems’ largely due to higher work pressure and longer work hours than in other jobs. A gender-specific health concern raised was that women working in the tourism industry continue working ‘well into their pregnancy.’ There was also a concern raised regarding workers who are exposed to toxic agents such as new cleaning products that have been introduced specifically for the benefit of the tourism industry.
Infectious and chronic diseases
Understandably, concern about sexually transmitted infections (STIs) including HIV/AIDS seemed to be high particularly in the health workers focus group. In Cárdenas, it was reported that 60% of those affected by HIV/AIDS in the community were directly or indirectly connected to the tourism industry. Although tourism is by far the most prominent economic activity in this community, overall the focus group participants in Caibarién did not consider tourism-related STIs to be a problem, however. Other concerns were related to perceived risks of vector-borne diseases, the potential re-introduction of cholera and the introduction of other exotic diseases.
Societal impacts
Corruption and other unlawful activities, and prostitution were reported by decision-makers and community participants in Cárdenas. The community focus groups in both communities specifically highlighted their concerns regarding societal impacts of tourism. Prostitution was acknowledged to be a general problem of tourism by focus group participants in Cárdenas, whereas ‘in Caibarién there is no prostitution like in other places.’ Harassment of tourists in the form of youngsters approaching visitors to ask for a gift or money was considered to be a problematic nuisance in both communities.
Environmental impacts
Pressure on waste management and beaches from contamination was noted to threaten environmental well being of Caibarién and Cárdenas. People reported increased volumes of waste as a result of tourism development and large number of visitors concentrated in a small area. This was noted to create ‘garbage collection problems.’
Mitigating programs and strategies
The study identified a wide range of programs in the communities that serve to mitigate the negative impacts of tourism, as summarized in Tables 2 and 3. Some of the programs are local adaptations of national programs, whereas others have been specifically developed for the local context.
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Noteworthy, as a national policy, was the creation in the year 2000 of the Projects Management Office at the level of the Provincial Assembly of the People's Power (provincial Parliament) in all 14 Cuban provinces. One of the tasks of these regional offices was the supervision of tourism projects and their impacts, as well as developing ‘community capacity’ and ‘health improvement’ by working with the community organizations and youth in particular.
The focus groups highlighted another national policy that serves tourist developments in particular, namely the strategic deployment of physicians with specialty in Occupational Medicine to all Cuban resort places. The role of these physicians, aside from attending to the medical needs of tourists, includes health promotion for tourism workers, vector control and prevention of diseases in tourism workers through vaccination and regular examinations.
Caibarién
‘Barrio debate’ (Neighborhood debates), a program also run in the whole country, that was identified by the groups in Caibarién, involved periodic meetings between officials and community dwellers to examine broad community concerns such as ‘sanitation problems.’ This initiative was reported to empower the community by creating the means to develop response capacities to mitigate the negative impacts of tourism including psycho-social impacts. From this program, initiatives, such as the completion of a new waste management system for the community and the enactment of legislation to ensure that one physician was placed in each resort hotel, had been implemented. Group members noted that all types of concerns could be voiced at this meeting and thus the group, while sponsoring direct mitigation efforts, was indirectly creating stronger social cohesion and reduced mental stress.
At a very local level, a program was reported to have been used in a neighborhood development for tourism workers called ‘Tarea Álvaro Reinoso’ (‘Alvaro Reinoso Task’). This was a national program widely used since the time of the Cuban economy restructuring in the early 1990s in order to address the massive layoffs of workers in the sugar industry and the subsequent shift to the tourism industry. Originally this program provided special retraining opportunities to workers but it was used today to ‘identify problems stemming from the local community’ through meetings and focus groups.
In response to increased alcoholism and drug abuse, focus group members in Caibarién observed that the municipal authority had developed two radio programs which aired each week for 1 h. The aim of both programs was to promote health education, while emphasizing the risks of alcoholism and drug abuse. The radio programs were thought to be specifically targeted towards at-risk populations such as those working within the tourism industry or youth prone to alcohol and drug use due to increased exposure to tourism.
Promotional and literacy pamphlets, developed in conjunction with the Provincial Centre of Hygiene and Epidemiology, also outlined the risks of alcohol and drug consumption as well as STIs, and promoted the use of condoms. Pamphlets had wide distribution in hotels and at local restaurants aided by industry workers themselves. Similarly, community health programming targeted tourism workers, students and school counselors through the distribution of educational material dealing with the health risks involved in prostitution, alcoholism, tobacco and drug use. It was noted that this educational material was available at tourism training institutes as well. In addition, community health workers reported visits to local schools in an effort to encourage discussion with students and school counselors in these areas. All the above efforts were financially supported by the Cuban government.
In dealing with increased pressure on the environment in Caibarién, programs were described that aimed to educate the local community on the relationship between health, environment and sanitation. ‘Mi Casa bonita, mi casa saludable’ (My beautiful home, my healthy home) was said to target households and it specifically ‘creates awareness in environmental health.’ Collecting waste and promoting clean surroundings and public places were among the tasks that people performed within this program.
In reference to the response to HIV/AIDS, education was noted as the primary strategy used by the government in an effort to promote prevention. One such effort was a contest held in Caibarién among local artists who were asked to create artwork around the theme of HIV/AIDS. Reportedly the art was infused with educational topics and placed on display. Also in Caibarién, media displays in schools were reported by the groups, as an additional effort to educate youth and students about the risks associated with the pandemic and adequate prevention measures to protect themselves.
Besides targeting specific public health areas or population groups, inter-sectoral coordination across areas of concern and within multiple sectors of the community were noted. In Caibarién, ‘Reunión del Sistema’ (System Meeting) was explained as a weekly meeting between healthcare professionals and community leaders from various sectors and levels of government. At these meetings, the issue of vector surveillance was routinely examined and decisions made regarding health interventions and interventions for community well being in general.
Cárdenas
The national level ‘Coraza Popular’ (Popular Shield) program which operates in all Cuban provinces was specifically noted in the focus groups in Cárdenas. This program, which started in January 2003, has as its original objective to end drug trafficking and selling, but through the community participation now also raises awareness about the harm derived from the use of drugs. Its results were noted to be ‘positive.’
In response to increased pressure on society, a program in Cárdenas known as ‘Acciones para la Creación del Turismo Positivo’ (Actions for the creation of positive tourism) was said to offer youth events such as arts, crafts, sport and dance twice weekly. It was thought that this sort of activity would improve the mental well being and coping mechanisms of youth participants. In addition, Cárdenas was noted to have employed community workers to advertise this youth program within the community, at the beaches in particular, and in so doing increasing community capacity to respond to health concerns. All events arranged for the youth were free, funded in part by municipal authorities and in part by local resorts as a ‘pay back or compensation’ to local communities.
In response to concerns about increased traffic accidents and fatalities, the municipality of Cárdenas had created the ‘Committee for Transit Safety.’ This committee met twice a month at city hall to discuss problems identified by police concerning traffic issues. The committee was responsible for promoting road safety and controlling five billboards in the municipality which displayed traffic safety information about seatbelt use, traffic laws and driving under the influence of alcohol. It was perceived by focus group members that this initiative had improved the community's infrastructure and decreased perceptions that tourism caused heavier traffic and associated injury.
Student Volunteer Brigades were reported to have been periodically dispatched to clean beaches and surrounding areas. In addition, the municipality had engaged research projects into the impacts of tourism on society and the environment, targeted to decision-makers at municipal levels.
Finally, local government committees existed to target problematic areas of STIs, addictions, safety and housing for tourists. It was reported that all community members were targeted by these issue specific committees.
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DISCUSSION |
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There is a considerable literature that has been developed to deal with health concerns associated with tourism (although a disproportionate amount involves travelers and not local populations). These range from mental health concerns (Scott, 1998
), violence and crime, (Kandela, 2000; Apostolopoulos and Sonmez, 2002) drug and alcohol addiction (Frechtling, 1997; Guerrier and Adib, 2000; McMurray, 2004), traffic-related accidents (Richter and Richter, 1999; Rodriguez-Garcia, 2001; Richter, 2003), environmental impacts (Frechtling, 1997; Stonich, 1998; Richter and Richter, 1999; Rodriguez-Garcia, 2001; Apostolopoulos and Sonmez, 2002; Richter, 2003) occupational health concerns (Scott, 1998; Guerrier and Adib, 2000; Richter, 2003), STIs (Rodriguez-Garcia, 2001; Apostolopoulos and Sonmez, 2002; Richter, 2003; McMurray, 2004; Huda, 2006) as well as sex tourism (Rodriguez-Garcia, 2001; Richter, 2003), infectious disease (Richter, 2003) and changes in healthcare structure and services (Frechtling, 1997; Apostolopoulos and Sonmez, 2002; Thompson et al., 2003).
To address the identified concerns, the Pan American Health Organization launched a quality tourism project to protect the health of tourists as a means of ensuring the economic viability of the tourism industry. There are indeed ample reasons to be concerned that economic pressures to develop tourism lead governments and the tourism industry to avoid reporting health risks to travelers (Richter and Richter, 1999; Apostolopoulos and Sonmez, 2002; Richter, 2003), which can be problematic. Just as important for sustainable tourism, however, is a much more neglected concern, namely the impact of tourism expansion on the health of the host community. Not only is research on the health impacts of tourism on local communities weak, adequate information on specific efforts to mitigate the health impacts of tourism development on local populations is virtually non existent (Frechtling, 1997).
In the case of Cuba, pressures on the population due to large influx of international tourists, recent and brisk development of tourism destinations, and the reluctant adoption of different lifestyles due to the ‘demonstration effect’ from tourists are pathways by which Cuban communities are experiencing impacts. Our research confirmed the existence of concern by local populations involved in international tourism; and our focus groups and interviews indicated that significant changes in many health areas do merit community response. We found that Cuba is indeed devoting considerable effort to mitigate the negative impacts of tourism, particularly in the form of health education and participatory programs. These educational programs, in keeping with the unique approach to health that Cuba has taken since the revolution in 1959 are embedded in a well developed, multi-sectoral healthcare system and an unparalleled social and political will to protect public health (Spiegel and Yassi, 2004; Yasi et al., 2003). Consequently, although Cuba only re-opened to international tourism in the past decade and a half and has seen a resurgence of some of the pre-1959 social ills as a result, Cuba is actively addressing the negative impacts in a systematic manner.
The literature talks about the importance of public education programs for tourists to minimize health problems including those related to travel-specific diseases, behavior modification, personal hygiene, food-borne diseases, sexual behavior and drug use. Some actions advocated to mitigate traffic-related deaths and injuries are better surveillance systems (Rodriguez-Garcia, 2001). As we saw from our study results, Cuba has actively promoted training programs for tourism workers in safety and health as well as an effective surveillance capacity. Some of these programs, of course, help mitigate both the impact on tourists and on the host community.
It has been increasingly well established that tourism creates greater exposure to drugs and alcohol attributable to work pressures and increased contact of local community members with tourists. Bellis et al. (2003), in their extensive studies of drug use by tourists in tourist nightclubs, call for more collaboration between sectors in the tourism industry, specifically suggesting educational programs for tourists to mitigate the health risks associated with drug use. The Cuban communities we studied consider youth to be the most vulnerable population in relation to addictions, and the mitigating policies adopted in these two communities especially targeted youth.
As a response to the spread of STIs through sex tourism, experts have suggested that sex trade workers be licensed to better monitor their health, that the general population be educated about safe sex practices, and that legal provisions to protect children from the sex industry be strengthened (Richter, 2003). Hansen and Groce (2003) noted a rise in HIV infection rates in Cuba in 1996 corresponding to increasing tourism but more recently the number of reported cases of AIDS dropped from 447 in 2002 to 147 in 2005 (Oficina Nacional de Estadística, 2005). This can likely be attributed to Cuba's rigorous and universally accessible public health measures to combat HIV/AIDS. Our focus group participants indeed concurred in that Cuba's HIV/AIDS prevention programs contribute to the decrease of infection rates despite the expansion of tourism.
Coinciding with larger trends towards greater environmental stewardship, the tourism industry has aimed to consider forms of sustainable tourism development (United Nations World Tourism Organization, 2007). From our findings, it would appear that a multi-sectoral strategies undertaken in Cuba, such as the ‘Barrio Debate’, have aided in improving sanitation infrastructure and education to promote ecologically friendly approaches to tourism development. As a focus participant expressed: ‘the concept [of health] has expanded and there is a tendency to take into account an environment free from pollution [for being] healthier.’ Stonich (1998) notes, for example, that to mitigate the negative impacts of tourism on island ecosystems, tourism businesses should monitor their own impacts as well as inform tourists about the social and environmental implications of their visit. Sensitive to such impacts, responses are increasingly being implemented, such as a case study from Namibia documenting the installing of water-saving technology at a main tourist camp (Bethune and Schachtschneider, 2004). Cuba is addressing environmental quality in its tourism communities by improving its sanitation infrastructure and creating programs that discuss sanitation and other environmental issues.
According to our findings, Caibarién, a community relatively new to engagement with tourism compared to Cardenas, has implemented more active and comprehensive mitigation measures in comparison to its older counterpart. The differences between these communities suggests that localities undergoing new or rapid integration into the world of global tourism may be learning from what has happened elsewhere, and are attempting to maintain strong community links to combat negative health outcomes. Although extrapolating from just two communities must be undertaken with caution, our findings suggest that newly affected communities might even be more willing to implement mitigation efforts based on local needs and multi-sectoral approaches than more established tourism locations, as it is easier to begin these efforts before less healthy practices are well established.
The variety of programs identified in the two Cuban communities studied shows creativity and a strong commitment to address the impacts of tourism. Although the results of such efforts cannot yet be determined, the efforts implemented by local communities are seen by community members as positive. More research into such efforts would prove fruitful for the many communities experiencing similar health challenges due to expanding tourism infrastructure.
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CONCLUSION |
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It is increasingly well established that the ability of communities to respond to the economic pressures of globalization is an important determinant of community health. This case study of two communities in Cuba illustrated that communities can create programs and improve infrastructure to sustain population health despite changes and burdens on lifestyles and environments from tourism development. Longitudinal studies are needed to assess the sustainability of these programs and to evaluate the impact of these measures in protecting health.
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MESSAGE |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONMESSAGEFUNDINGREFERENCES |
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Although prospective studies are needed to evaluate the long-term effectiveness of mitigation strategies, the significant commitment to tackle the negative impacts of tourism in Cuba provides lessons from which communities elsewhere can learn.
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FUNDING |
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Canadian Institutes of Health Research (CIHR) 17R90994. Funding to pay the Open Access publication charges for this article was provided by the CIHR.
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ACKNOWLEDGEMENTS |
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The authors thank research study team members (Nino Pagliccia, Mabel Font and Orlando Diaz) who played an active and critical role in collecting data for this study; research program team members (Gerry Veenstra, Olena Hankivsky, Nelly Salgado, Brian Wilson, Susan Stonich, Daniyal Zuberi) who contributed ideas at workshops held to discuss the development of the project; The Michael Smith Foundation for Health Research and the Institute for Population and Public Health (CIHR); community representatives in Caibarien and Cardenas who enabled the research to be conducted and to Ariadna Fernandez, Lucia Egbert and Jo-Anna Gorton for their work in assembling the paper through its development and many drafts.
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