P r e v e n t i o n in S w e d e n and Cuba: Implications for Policy R e s e a r c h A R T H U R G. NIKELLY A B S T R A C T : Sweden and Cuba, each in its own way, have made radical and comprehensive changes in t h e i r economic, educational, and social systems. In the process, they have corrected m a n y contradictions about h e a l t h promotion, which has, in turn, enhanced the effectiveness of t h e i r primary prevention programs. There is much for h e a l t h care planners and public policy strategists to learn from these two social and economic experiments.

There has been an enormous increase in the delivery of health care in the United States, and the level of our medical and psychological expertise is among the highest in the world. Yet, the incidence of physical and emotional problems has not been reduced. Despite the widely accepted principle that many emotional and physical problems are preventable, little concerted effort has been made to avoid these problems. Among the reasons for this failure is the fact that preventive measures of such magnitude necessarily involve changes in a socio-economic system whose effects on h u m a n functioning are only beginning to be recognized by researchers and therapists.

Effects of the Economic Structure Current medical and psychological practice is designed to reduce the incidence of disease or mental health problems through cure, on the assumption that the greater the efforts to cure, the greater the likelihood that a disease or emotional problem will be eliminated. It also assumes that comprehensive prevention programs can be effective when implemented from privately based or local institutions. The community prevention system in the U. S. is an aggregate of temporary programs and diverse agencies. Without sustained aid and persistent guidance from a central authority, each program has its own goals and priorities. A r t h u r G. Nikelly, Ph.D., is Clinical Psychologist and Associate Professor of H e a l t h Science in the Mental H e a l t h Division of the University of Illinois Health Center at Urbana. Requests for reprints should be sent to Dr. A r t h u r G. Nikelly, University of Illinois H e a l t h Center, 1109 South Lincoln Avenue, Urbana, Illinois 61801. 117

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Such a system seems to reflect the individualism and competition characteristic of American society at large. Bloom (1984) has offered a model, a paradigm similar to the concept of "planned communities" where prevention efforts become institutionalized across the whole country, that suggests the magnitude of the response required before the U. S. can be said to have a prevention program. Instead of the current approach which focuses on pockets of risk groups, of vulnerable persons, and limited target communities, a prevention program must encompass the total population of the nation. Research on the economic factors that create stress and pathology is a fairly recent phenomenon. Consider, for example, the review of Seidman and Rapkin (1983). Suicide, crime, schizophrenia, functional disorders, delinquent behavior, and psychological stress reactions are all significantly higher among persons of low socioeconomic status. Further, unemployment is definitely associated with higher crime and hospitalization rates, and criminal behavior increases as the economy declines. Brenner (1973) found an association between unemployment and economic recession and an increase in physical and emotional disorders and in hospitalization rates. Kessler and Albee (1975) argue that there can be no prevention program without abolishing poverty, unemployment, and social discrimination. Prevention programs covering the entire population will, therefore, be difficult to implement without radical social reform and change. It is these structural changes, however, that will eventually bring about changes in values and life styles. The literature on primary prevention suggests that efforts for change in the U. S. have been of a much lesser magnitude. Directed toward individuals, groups, and communities, they have been based on the premise that a "rippling" effect would eventually reach the whole population. In other countries the prevention movement is more closely aligned to a restructuring of the economy through central planning so that the effects of change are more comprehensive. In general, health programs in the U. S. are fragmented, rely too heavily on treatment, place undue emphasis on the responsibility of the individual to manage his or her own health care, and are unresponsive to the growing body of data that points to the relationship between various indices of ill-health and poverty. Based on demographic surveys, research data, and cultural studies, this paper undertakes to describe and compare preventive and health care programs in Sweden and Cuba, suggesting how the programs are organized, their effects on health, and implications for the develop-

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ment and refinement of health policies and prevention strategies in the U.S.

The Welfare System of Sweden Sweden's economic structure is based on the concept of solidarity, a concept that implies unity of purpose and acts as an incentive for productivity for the benefit of all, as opposed to productivity for personal gain. Solidarity also implies the sharing of material wealth; everyone has the right to equal access to the resources of society. Thus, real freedom is found in economic equality, not in unregulated economic competition where the unsuccessful are excluded from the community. In contrast, economic freedom spawns economic inequality, which in turn produces inequities in personal freedom. Prosperity in Sweden is thus distributed in order to create an economically homogeneous population by eliminating pockets of poverty and wealth. Hence, wage differentials have been reduced and profits distributed to the consumer in salaries and subsidies. As a result, a new morality has emerged in Sweden, one that is directed against competition, individualism, and consumerism. The goal of prevention in Sweden is the elimination of environmental conditions that cause h u m a n distress. Personal problems are considered reflections of social ills that must be altered before individual intervention can be effective. Harmful living conditions are corrected by social policies that support a homogeneous economic prosperity for all persons. The distribution of material benefits has created material security, eliminated disadvantaged classes, reduced unemployment, and created a strong health care program. The unemployment rate in Sweden is around 3%, and there is a systematic and intensive program to retrain unemployed workers to fill available positions. Health care services are not provided by the private sector but are furnished to all members of the society by the county and national governments. Trade and industry decisions are influenced by cooperative enterprises rather than, as in the past, by those vested with economic power (Heckscher, 1984). While such a social and economic philosophy has fostered a high standard of living, it has also created a dilemma because it views deviance as caused by environmental factors rather than individual tendencies. If personal problems merely reflect environmental conditions for which the State is accountable, the responsibility for individual be-


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havior is diminished. As parents abdicate their obligations to raise responsible children and assign the task to the State, their influence as role models is eroded. Again, the environment is blamed for personal transgressions. This circular phenomenon may help to explain why the crime rate has not abated in Sweden during the last decades (Heckscher, 1984). Psychotherapeutic services in Sweden are available to all citizens, a plan known as sectorization, whereby the country is divided into catchment areas, each with all types of health care--social, rehabilitative, residential, child, marital, gerontological, family, addictive, acute, chronic, inpatient and outpatient services. There is a strong emphasis on prevention, and emotional disturbance is viewed within a social context rather than as an individual illness requiring inpatient care. Health care policies are democratically administered and centrally organized with an emphasis on planned prevention (Seeman & Kerstin, 1984). Not only do the Swedes attempt to reduce and solve existing social problems but they also attempt to integrate prevention planning with the environmental factors that breed these problems. They achieve these goals through outreach programs, case-finding activities, and a well-developed information and counseling system. They also rely on child development services and provide transportation facilities, housing, medical care, and financial subsistence. Sweden's comprehensive social health care system is based on universal medical coverage supervised by the central government and administered by local authorities. Inpatient and outpatient treatment and medicines are free or inexpensive. Insurance benefits cover accidents, illness, unemployment, old age, occupational injury, pensions for the mentally and physically disabled, and childbirth and child support payments for single parents. In addition, there are collective benefits for child care and school lunch programs with fees regulated by income. Finally, education is free and housing is subsidized by the government (Heckscher, 1984). To prevent premature or unnecessary institutional commitment and to serve the needs of an increasingly aged population, the Swedish government has instituted an "open care" service that provides universal access to a home or community-based health care system. Open care provides service homes or residential hotels to all senior citizens; those with higher incomes pay fees on a sliding scale. Home-help services, meals, transportation, recreational and occupational activities, shopping, housekeeping, and personal and clothing care are provided. Med-

Arthur G. Nikelly


ical care is available on call, and pensions provided by employers or by the government are allotted to each person (Little, 1978). Sweden, like other Western industrialized countries, has a homeless population, but the government organizes efforts to rehabilitate this population. The Bureau of Homeless Men in Stockholm is a unique organization that has no equivalent in other countries. Its function is to place men without homes in comfortable living conditions and to coordinate follow-up care, since many of them are either alcoholic or have incapacitating emotional problems. Referrals are made for medical or psychiatric interventions on an outpatient basis or within an institutional setting. Vocational rehabilitation is undertaken and sickness and disability pensions are arranged (Asander, 1980). Every municipality in Sweden maintains a Temperance Board to handle cases of alcohol abuse on an outpatient basis or at medical centers. This Board also undertakes follow-up care after alcoholics are discharged from hospitals and during their probationary status. Approximately 70% of the known alcoholics in Sweden are registered at these Boards (Ojesjo, 1980). Since drug and alcohol abuse often denote personal or interpersonal problems, primary prevention in Sweden begins with a unique compulsory program in the grade schools. School staff known as "pupil welfare teams" offer activities in which youngsters learn about themselves and how to cope with daily problems. One goal of the program is to help young students make independent and responsible decisions on alcohol, drugs, and tobacco. Running parallel to the school program is an anti-alcohol movement sponsored by governmental and private organizations (military forces, employee unions, broadcasting systems) and strict regulations against drunken driving. Finally, Sweden provides mandatory care of alcoholics and drug abusers whose mental health and physical well-being are endangered. As a result, alcohol and drug abuse have declined in recent years (Blomberg, 1982). In contrast to the profuse and indiscriminate advertising practices in many other countries, the advertising of alcohol and tobacco on radio and television is forbidden in Sweden; promoting alcohol and tobacco in print media directed at youth is also prohibited by law. Thus, Sweden issues a consistent message throughout the country--unlike the conflicting signals citizens, and especially young people, receive in free-enterprise societies. While both the U. S. and Sweden attach health warnings to cigarettes and publicize information on the hazards of smoking, Sweden has gone on to implement a centrally administered, long-term, comprehensive campaign to cultivate a negative atti-


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tude toward smoking. Its objectives are achieved through the mass media, the schools, medical and civic institutions, the work place, and through person-to-person persuasion. Anti-smoking education in Sweden begins in grade school prior to the normal smoking age; it continues through high school, where it is integrated into various academic subjects. The result has been a steady decline in smoking rates and smoking-related diseases (Ramstrom, 1983). These economic, social, and medical innovations have elevated the well-being of Swedish citizens. The annual death rate of infants under one year of age in Sweden is 7 infant deaths per 1,000 live births, the lowest rate in all Europe (Kent, 1983). The reason for this low infant mortality rate seems to be the strong emphasis on prenatal care. Sweden has also launched a general parent education program as an added preventive measure against childhood disorders. The program is directed toward the whole population of parents and parents-to-be. Introduced in 1979, the program covers the theory and praxis of effective parenting, beginning with pregnancy and continuing through the first year of the child's life (Fagerberg & Olin-Lauritzen, 1982).

The Humanistic Society of Cuba For over two decades Cubans have been developing a humane society by altering the most fundamental factor--its economic structure. No longer .do the fluctuations of a market economy insure profits to a few and victimize the losers. Economic planning in Cuba aims to distribute wealth by allowing workers to operate the means of production and by eliminating the private ownership of raw materials. Cubans have reduced the incentive for profit and expansion, rejecting self-satisfying ambitions, they have deemphasized individual liberty and stressed a commitment to the collective well-being of the society. The development of social consciousness is an expressed goal, and the virtue of work is extolled. Society in Cuba is fashioned on the ideals of common purpose and communal activity. It provides for the basic needs of all citizens, and work is geared toward collective goals. Work, in Cuba, is part of one's identity and self-esteem, and it is a right guaranteed by the constitution. While material incentives for work in Cuba are not discouraged, Cubans also stress that material benefits are the consequence of a primarily moral incentive. In a humanistic society work is expected according to ability, and personal fulfillment is attained through sharing in the production process. It is

Arthur G. NikeUy


a social and economic system in which people work toward meaningful personal goals that are beneficial to all. Communal ownership of land, as in the case of cooperatives, is a logical extension. Health care in Cuba is free and universal and is considered a h u m a n right, not a privilege. It is provided by well-staffed polyclinics organized by geographic areas. Medical practitioners look for social solutions and deal with the environmental determinants of disease. Physicians are trained in nutrition, epidemiology, and community medicine. There is strong emphasis on prenatal care, health education, and social planning with health programs that cover the entire population (Danielson, 1979). But what makes Cuba unique in primary prevention are its outreach programs. Primary prevention in Cuba begins in the community. Every adult is expected to be examined annually by a physician-nurse team; however, this plan has not fully materialized because a small proportion of citizens fail to go for the medical check-up. Infants to the age of one year are scheduled to visit a pediatrician twice a month; those from two to five years old have two appointments each year (Ubell, 1983). Whether or not these appointments are universally kept, however, is not known. In addition, medical teams plan house calls to patients who require sustained medical care but who do not keep their scheduled appointments. In addition to scheduled appointments every three months, patients with chronic illnesses and adults age 65 and over are visited at home once a year by a medical team. In some cases expensive but necessary medications are paid by the state when patients cannot afford them. Workers and high-risk groups receive ongoing physical check-ups (Gomez, 1978), and pregnant women make hi-weekly visits to obstetric centers (Sloan, 1978). Teams of nurses and physicians are allocated 12 hours per week to canvass the community and survey local health conditions and to make home visits on a nondemand basis (Perez-Stable, 1985). Other teams may advise high school students on birth control or consult with workers in water purification plants. Thus, the goal of medical and psychological prevention in Cuba is to promote public health through social change and community education and to eliminate environmental stress (Bernal, 1985). Primary prevention is an all-out effort through families, schools, factories, and community organizations (Averasturi, 1980). In spite of the universal, free health care system in Cuba, deficiencies in the system remain, such as understaffed clinics, long waiting periods, the overuse of medical facilities because medical care is free (Perez-Stable 1985), and the stigma against the mentally ill (Marin,


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1985). Nevertheless, the Cuban experience makes clear that the prevention of potential problems not only involves early detection and surveillance of high-risk populations, but also changing the contingencies that affect those problems. For instance, participation in organizations not only shapes attitudes toward mental health but also educates the public, implements the goals of society, offers enormous psychological support, and acts as a buffer against stress. Because its health care is available to all segments of the population, Cuba has been able to achieve the health profile of a developed country (Camayd-Freixas, 1985). This goal is reached by the active efforts of organizations that carry their work into the community--municipal assemblies, trade unions, and farmers' groups. These groups organize and mobilize the whole population--a goal that physicians could not accomplish without strong community support. For instance, a recent dengue epidemic was contained in a few months through the intervention of all-out sanitary operations, educational campaigns, and consultation sessions within the entire community (Perez-Stable, 1985). Primary prevention in Cuba is fostered by basic social policies that equalize educational and economic conditions and permit access to full employment and health care resources. The result is that blacks are not overrepresented in the psychiatric population, and the suicide rate in Cuba is about equally distributed by race, occupation, and education. Similarly, cirrhosis of the liver, homicide, and self-destructive deaths are lower in Cuba than in many developed countries (CamaydFreixas, 1985), and there is no illicit drug use (Marin, 1985), partly because of strict laws and partly because of the absence of the personal profit incentive. There is a dearth of data on alcoholism because Cubans do not consider it an urgent public health problem. One reason alcoholism is not prevalent is because the price of alcohol in Cuba makes its abuse economically impossible for most Cubans. Nevertheless, indications from the treatment of alcoholics suggest an early onset of alcohol consumption for some youth, and higher incidence among those with easy access to alcohol--employees in restaurants, bars, and distilleries (Camayd-Freixas, 1985). While many other health-oriented preventive programs have been undertaken with considerable success, an allout campaign against alcohol and tobacco abuse, like that in Sweden, has not been adopted in Cuba. Despite the known deleterious effects of tobacco use on cardiovascular disease, no systematic preventive efforts against smoking exist. Although statistics are not yet available, smoking consumption among Cubans is very high and health-care providers

Arthur G. Nikelly


are becoming alarmed by this observation. Since Cuba is a tobaccogrowing country, it is difficult to discourage citizens from consuming their own product. Despite the beneficial effects of social planning, the new society in Cuba has created its own endemic stress precipitated by radical economic reforms, demands for sexual equality, a weakening of the extended family support systems, a demanding work pace, urbanization and relocation, intergenerational ideological clashes within families, changes in social and economic values and priorities, adaptation to automation, and greater expectations from new political and social responsibilities. These stresses are mitigated by diminished insecu~ rity over unemployment, by decreased social class distinctions, by strengthened social support structures (for example, membership in organizations that generate feelings of control and participation in making changes), by the use of the media to educate the public to focus on social goals, by humanized relationships between work and production, and by a sense of community cohesiveness among a broad segment of the populace (Camayd-Freixas, 1985). Predicated on the theory that individuals from childhood internalize humanistic values when the good of society is placed above personal interest, a national, free, day-care program for preschoolers was begun in Cuba. Meals, clothing, and comprehensive medical care are part of the program. There is an intensive effort to provide psychologically positive experiences as well as to stimulate intellectual functioning. Children are encouraged to practice activities that correspond with the mastery of pro-social skills (Leiner & Ubell, 1972). This form of education can best be described as ethoplastic because it aims to form good character, and to prepare the child for later academic and personal growth. Cuba also provides basic sex education for all children. There is strong emphasis in the nurseries on learning cooperation and on breaking down sexist attitudes. For instance, when playing house or hospital, boys feed and care for dolls and play "nurses," while girls play the roles of providers and "doctors." Each child learns to help the other, and to understand that no one has authority over another person. Instead of competition, which results in winners and losers, pupils practice emulation, which involves identifying with group goals. Group identity is thereby reinforced, which gives strength and purpose to individual members. Secondary schools in Cuba are located in agricultural settings, where work is part of the daily curriculum. These high schools are fully equipped work/study boarding schools in the countryside where


Journal of Primary Prevention

students attend classes and work in the surrounding fields. In this way the school meets its food needs and students learn the value and dignity of work. Students are also admitted to technical and career training institutions according to the needs of the society at a particular time (Katzin, 1975). Educational reforms in Cuba, aided by a national inservice training program to improve teacher quality, have almost completely eradicated illiteracy. While intelligence and ability testing are not used and equality of opportunity in education is stressed, there is emphasis on achievement. Necessity dictates educating superior students with high scholastic achievement by having them attend special advanced schools. However, some feel that these elite schools may contradict the humanistic philosophy of equality in education (Leiner, 1981). Approximately .5% of Cuban youth become alienated and antisocial and are referred to re-educational centers for study, training, and labor and to learn resocialization through involvement with cultural, recreational, and political activities (Shaw, 1983). The reasons given for delinquency are economic hardships which required sacrifices that are difficult for youths to make who expect immediate material rewards. Poor role models created by unstable home environments, single-parent families which lack direction and cannot supervise their children closely, and the lure of material values from the U. S. cause some youths to remain unintegrated in Cuban society. Prevention is achieved through early detection of academic and behavioral problems. Multidisciplinary teams in diagnostic and orientation centers assess the deviant child, with input from parents and teachers, and recommendations are made either to special schools or to the student's school. Instead of defining the problem in terms of the child's internal psychological conditions, Cuban psychologists view it as a social issue that requires social solutions. Thus, the child is not treated in isolation but all those involved with the child are consulted, and often counseled (Shaw, 1983). Partly as a result, the crime rate in Cuba has decreased by one half from 1959 to 1968 (Salas, 1979). To eliminate malnutrition Cubans attacked its source--economic inequality. Instead of producing food for profit, "food equity" has been established to meet the nutritional needs of the population. Through judicious rationing the government insures the right of all Cubans to a balanced and nutritious diet. All students receive a free lunch at school, and extra nutrition is provided to pregnant women to insure healthy prenatal care. More recently, efforts are being made to change poor eating habits that were instilled from the colonial years because

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of the poor quality of food at that period. Food and clothing are rationed at low prices so that they are available and affordable to every citizen. After the basic nutritional necessities are met for all the population, food is allocated to a "parallel market" that carries less necessary items at higher prices. There are also "farmers" markets operated by farmers themselves, not by the state. Homelessness in Cuba is a rarity because the government provides housing for all citizens. Although the vast majority of Cubans live in adequate dwellings and new housing units are being built at a rapid pace, some families remain crammed into small apartments, while others live temporarily in bohios where many homes are in need of repairs. Even these families, however, do not live at the poverty level because they have steady jobs and are provided with adequate food and medical care; their children also receive free education. Cubans have met the needs of the elderly through a national policy that guarantees housing, food, heath care, clothing, recreation, and transportation. A national network of homes for the elderly has been established. Each is governed by its own residents, some of whom are permanent, while others visit on a day-time basis. Retirement is voluntary and retired Cubans are kept active and involved in civic and other part-time work that gives them dignity and makes them feel useful and wanted (Schulman, 1984). The employment and educational status of women has improved, and more women are entering technical and professional fields with equal pay for equal work. Similarly, approximately 20% of political officeholders are women. Despite the enormous efforts of the feminist movement, however, full sexual equality in Cuba has not been achieved. Women remain at the lower political levels, and many are tied to domestic tasks. Sexism has not been fully eradicated, and the divorce rate remains high. The main obstacle to equality is the lingering "machismo" attitude among Cuban males; however, violence against women (spouse abuse and rape) now appears to be fairly uncommon in Cuban society (Wishnia, 1985). Despite the continuing embargo, the Cuban government has not made cuts in housing, education, public health, and community services. Furthermore, there are no noticeable economic fluctuations, high unemployment does not exist, and there is no wide income discrepancy (Fuller, 1984). Finally, Cuba's latest infant mortality rate is 15 infant deaths per 1,000 live births per year (Granma, 1985). Similarly, life expectancy has increased from 58 years in 1958 to 73 years in 1981 (Aldereguia & Aldereguia, 1983).


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Summary and Conclusions Sweden and Cuba have undertaken structural reforms through macroenvironmental planning, including the elimination of special interest groups, an equitable distribution of wealth, drastic reduction of unemployment, and economic stabilization at the price of economic growth. The situation in both countries is imperfect, but health conditions continue to improve through primary and secondary prevention that encompasses broad environmental contingencies which, while not exactly identical in degree and design, seem to be based on the same principles. Six general conclusions emerge from the foregoing data that may have relevance to prevention efforts in our own health care system. First, unlike other developed countries where health care is considered an economic privilege, Sweden and Cuba hold it to be a human right; as a result, the state assumes the responsibility of developing, maintaining, and delivering a homogeneously distributed health care system. Second, Sweden and Cuba support an open and free health care delivery system on a national scale; every person beginning early in life, has access to health care. Third, the health care systems of Sweden and Cuba reach out into the community to eliminate conditions that produce disease and stress (primary prevention); periodically the health care systems of the two countries screen the healthy population (secondary prevention). Fourth, educational values fostered by the Swedish and Cuban school systems minimize individualism, competition, and consumerism. Instead, cooperation and community feeling are nourished, and collective needs take precedence over individual ambitions. Fifth, the economic systems of Sweden and Cuba have changed along with the world of work, a transformation that suggests a change in the values of society and the fabric of interpersonal relationships. Sixth, voluntary citizen participation in community affairs (more true for Cuba than for Sweden) affords greater opportunities for citizens to influence and support prevention and health maintenance goals. Thus, Sweden and Cuba have developed a socioeconomic environment that facilitates primary prevention efforts. Another reason why prevention programs have been successful is because both countries are relatively small and geographically contained, and consist mainly of culturally homogeneous and socially less complex populations. While both countries continue to face problems, both have made significant progress that can be documented. In spite of differences, a ba-

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sic characteristic is found in these two societies--consistency of vision and the establishment of priorities that work synergistically to promote health and welfare. Health-care systems motivated solely by competition and material incentives to control or to acquire power are not found in either country. Although comparisons of health systems are difficult and require cautious interpretation, the rigorous study of primary prevention outcomes in Sweden and Cuba might well have a positive influence on the health-care system in our own country. Similarly, a study of prevention programs in capitalist democracies like Japan and West Germany may reveal additional information to enhance our health-care system. The experiences of Sweden and Cuba demonstrate that the educational and socio-economic structure of a nation cannot be isolated from the quality and magnitude of its prevention programs. Their innovations can serve as guidelines for the health-care planners and public-policy strategists who stand on the frontiers of primary prevention in the U. S. There are attitudinal differences toward health-care and prevention in the U. S. that make it difficult, if not impossible, to replicate the programs of Sweden and Cuba. For instance, Americans avoid putting money in prevention because it does not earn immediate monetary gains as do investments in lucrative businesses. Similarly, assumptions made by American society at large work against prevention programs. Consider, for example, the advertising industry whose primary purpose is to help manufacturers make profits by encouraging the consumption of products, many of which--like cigarettes and tobacco--are harmful to the consumer. Other advertisements foster a false faith in patent medicines and unrealistic expectations regarding cosmetics and other "beauty" products. Even professional organizations assume on scant evidence that prevention programs cannot work. A report by the Group for the Advancement of Psychiatry (1983), reappraising the effects of prevention in the community psychiatry movement during the past 20 years, concludes that primary prevention and broad social programs have not significantly lessened morbidity. Instead, the Group concludes that treatment, institutional care, rehabilitation, and aftercare should have greater priority because they are more effective than primary prevention. Many Americans hold the illusion that material possessions somehow ensure comfort, peace, and well-being. They also value individualism, free enterprise, self-sufficiency, competition, and the right to private property--all in contradiction to the basic Judeo-Christian tradition that places the welfare of the community above individual in-

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terests. Despite the subsidizing of health-care programs, there is an often unverbalized acknowledgement that unemployment, mental illness, crime, and other forms of evil will always exist in any society, regardless of efforts to eradicate them. While unemployment can be reduced by requiring corporations to behave in socially responsible ways, by encouraging worker participation and community ownership of the means of production--for example, leasing to workers industrial plants or productive land--especially in areas no longer profitable for large companies, these strategies are difficult to implement without government support (Catalano & Dooley, 1980). Even though the role of government within a democratic framework is to insure the health and safety of all its citizens, the responsibility for these prevention objectives is generally placed on individuals. Finally, the prevailing fallacy in prevention has been the effort to change individuals so that they are able to adapt to an environment that is often the primary cause of their maladjustment--in spite of the overwhelming evidence that environmental influences are more significant than personal or demographic variables combined (Swift, 1980). Thus far, changes in the environment to enhance mental health have been limited and superficial, and while the quality of medical and psychological services in the U. S. is among the highest in the world, the economic structure fosters an unequal access to health-care (Starr, 1982). Nevertheless, positive but limited results have been achieved mainly through consultation and education strategies. The foregoing data suggest that only through the elimination of poverty and unemployment and access to an open, national health-care system will the mental and physical well-being of the American population be improved significantly.

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Brenner, M. H. (1973). MentalIllness and the Economy. Cambridge, Mass.: Harvard University Press. Camayd-Freixas, Y. (1985). Psychiatric social epidemiology in Cuba: Issues in morbidity and mortality. Journal of Community Psychology, 13, 173-193. Catalano, R. & Dooley, D. (1980). Economic change in primary prevention. In R. H. Price, R. F. Ketterer, B. C. Bader, & J. Monahan (Eds.), Prevention in Mental Health: Research, Policy, and Practice (pp. 21-40). Beverly Hills, Calif.: Sage. Danielson, R. (1979). Cuban Medicine. New Brunswick, N. J.: Transaction Books. Fagerberg, P. & Olin-Lauritzen, S. (1982). Parent education as primary prevention. Nordisk Psykologi, 34, 122-130. Fifteen Per 1,000 Infant Mortality Rate. (1985, February 3). Granma, p. 3. Fuller, E. (1984, March-June). Cuba negotiates rescheduling of foreign debts. Cuba Update, pp. 5-6. Gomez, M. (1978). Working is safer. Cuba Review, 7, 29-30. Group for the Advancement of Psychiatry (1983). Community psychiatry: A reappraisal, No. 113, New York: Mental Health Materials Center. Heckscher, G. (1984). The Welfare State and Beyond: Success and Problems in Scandinavia. Minneapolis: University of Minnesota Press. Katzin, D. (1975). Education and revolution are the same thing. Cuba Review, 5, 3-36. Kent, M. (1983). 1983 World Population Data Sheet. Washington, D. C.: Population Reference Bureau, Inc. Kessler, M. & Albee, G. (1975). Primary prevention. Annual Review of Psychology, 26, 557-591. Leiner, M. (1981, December). Two decades of educational change in Cuba. Journal of Reading, 25, 202-214. Leiner, M. & Ubell, R. (1972, April). Day care in Cuba: Children are the revolution. Saturday Review, pp. 54-58. Little, V. (1978). Open care for the aged: Swedish model. Social Work, 23, 282-287. Marin, B. (1985). Community psychology in Cuba: A literature review. Journal of Community Psychology, 13, 138-154. Ojesjo, L. (1980). Prevalence of known and hidden alcoholism in the revisited Lundby population. Social Psychiatry, 15, 81-90. Perez-Stable, E. (1985). Community medicine in Cuba. Journal of Community Psychology, 13,124-137. Ramstrom, L. (1983). Smoking Control in Sweden. Stockholm: Swedish National Smoking and Health Association. Salas, L. (1979). Social Control and Deviance in Cuba. New York: Praeger. Schulman, K. (1984, July-August). Care for the elderly. Cuba Times, 4, 3-4. Seeman, K. & Kerstin, L. (1984). Psychotherapy in Sweden: Historical background, current status, and future projections. American Journal of Psychotherapy, 38, 97-110. Seidman, E. & Rapkin, B. (1983). Economics and psychosocial dysfunction: Toward a conceptual framework and prevention strategies. In R. Felner, L. Jason, J. Moritsugu, & S. Farber (Eds.), Preventive Psychology: Theory, Research, and Practice (pp. 175-198). New York: Pergamon Press. Shaw, K. (1983, Spring-Summer). Youth in trouble. Cuba Times, 3, 23-26. Sloan, D. (1978). The revolution delivers. Cuba Review, 7, 19-20. Starr, P. (1982). The Social Transformation of American Medicine. New York: Basic Books. Swift, C. (1980). Primary prevention: Policy and practice. In R. H. Price, R. F. Ketterer, B. C. Bader, & J. Monahan (Eds.), Prevention in Mental Health: Research, Policy, and Practice (pp. 207-236). Beverly Hills, Calif.: Sage. Ubell, R. (1983). High-tech medicine in the Caribbean. The New England Journal of Medicine, 309, 1468-1472. Wishnia, J. (1985). A revolution within a revolution. Cuba Times, 5, 9-13.

Prevention in Sweden and Cuba: Implications for policy research.

Sweden and Cuba, each in its own way, have made radical and comprehensive changes in their economic, educational, and social systems. In the process, ...
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