Cristian Morales, an economist by training, has dedicated his career to improving health and health equity in the Americas through his work with PAHO/WHO. This has taken him from floods and earthquakes in Haiti to PAHO’s Washington DC offices, where he was instrumental in achieving consensus on a resolution aiming for universal health—coverage plus access—approved by all governments in the Americas. Since 2015, he has served as PAHO/WHO Permanent Representative in Cuba and has recently been appointed to the analogous post in Mexico. At the end of his three years in Havana, MEDICC Review talked with Dr Morales about his experience, the Cuban health system, and the values it shares with the organization he represents. This is part one of the interview, the second part to be published in our January 2019 issue, in which we’ll talk more about the health system in Cuba itself, its achievements and also its challenges.

This roundtable began with world-renowned US and Cuban experts in arboviruses (particularly those transmitted by mosquitoes) but was quickly transformed with the participation of globally recognized scientists in other fields. All have contributed and continue to contribute to the often frustrating efforts to advance bilateral health cooperation, for the benefit of the USA, Cuba and the world. Each from their own vantage point argues why such cooperation can release potential to create scientific synergies capable of addressing some of the most perplexing and urgent global health problems.

Full disclosure: chief weather forecaster is not his official title, but rather one affectionally conferred on Dr Rubiera by the Cuban people, who look to him not only in times of peril, but also to learn about the science of meteorology. Anyone who has taken a taxi in Cuba during hurricane season (June 1 to November 30), and bothered to ask the driver, will receive a clear explanation about how hurricanes are formed, what the Saffir-Simpson scale is all about, and how the season is shaping up—all courtesy of Dr Rubiera’s talent for communication during nightly weather forecasts and special broadcasts. It’s no exaggeration to say that he is something of an icon in Cuba, a man people trust.

Now, he is retired as chief of forecasting at Cuba’s Meteorology Institute, but he stays on as an advisor, and since 1989 represents Cuba’s Meteorological Service as the Vice Chairperson of the World Meteorological Organization’s Hurricane Committee for Region IV (North America, Central America and the Caribbean). He also keeps a spot on nightly news and hosts two TV shows of his own: Global Weather and Weather in the Caribbean. And his PhD in meteorology serves him well as full professor at the University of Havana in—what else?—meteorology communications.

Finally, he has been a driving force in Cuba for collaboration with Miami’s National Hurricane Center (NHC) and other US meteorologists (in fact, the Chairperson of the Region IV Committee is the head of the NHC).

But, as he says over a cup of rich Cuban coffee, it all started with a two-year-old in a yellow sweater.

Mientras recorría las nieves del Himalaya para atender pacientes después del te-rremoto de Pakistán en 2005, el internista Félix Báez nunca podría haber imaginado que nueve años más tarde estaría en la primera línea del enfrentamiento al ébola en Sierra Leona… y mucho menos, que  contraería el mortal virus, sobreviviría para contarlo y además, que regresaría con sus colegas a África para continuar la batalla. A su lado, en el Hospital Universitario de Ginebra a donde fue transportado por vía aérea, estuvo el Dr. Jorge Pérez, hoy director del Instituto de Medicina Tropical Pedro Kouri (IPK) de Cuba, pero más conocido como “el doctor cubano del sida”. Para ambos médicos los tiempos han cambiado, y ahora, cuando el ébola hace estragos, es lo primero en sus mentes,

Al momento de esta entrevista, aunque existe un optimismo cauteloso en Liberia, la epidemia no está aún bajo control. El ébola ha infectado cerca de 22 000 personas, llevándose consigo más de 8 600 vidas; Sierra Leona es uno de los países más golpeados. Entre los contagiados y las víctimas mortales ha habido muchos trabajadores locales de la salud: 103 de los 138 infectados según la última cuenta.

El primero en lanzar la alarma global fue Médicos sin Fronteras, quienes, como Cuba, ya tenían personal médico en tierras africanas. A estos se unieron muchos otros, y Cuba fue el país que ofreció la mayor ayuda una vez que la OMS hizo el llamado a las naciones para hacer frente a la epidemia con financiamiento y, más importante aún, con recursos humanos.

Cuba envió 256 voluntarios, todos con una sólida experiencia en emergencias internacionales: 38 a Guinea, 53 a Liberia y 165 a Sierra Leona. Y otros esperan a tomar el relevo, todos trabajadores de la salud entrenados en desastres y que han recibido ya un primer curso sobre ébola en el IPK.

Estos cubanos y otros voluntarios internacionales están logrando salvar a pacientes de una muerte segura, apoyando a los trabajadores de la salud y los educadores comunitarios locales. Y personas como Jorge Pérez están trabajando a fondo en la investigación del ébola para ayudar a evitar su diseminación por toda África y otras zonas del mundo.

Pero evitar que otra epidemia así tenga lugar nuevamente, requiere más, mucho más. No solo la comunidad internacional pudo haber hecho más esta vez. Sino que, como advirtió Jim Kim,  Presidente del Banco Mundial, el ébola no empezó con la enfermedad, sino más bien con las desigualdades históricas, enconándose el virus en sistemas de salud que apenas logran funcionar. Una lección para todos nosotros.

Horas antes de que el doctor Báez regresara a Sierra Leona —donde se encuentra actualmente— MEDICC Review lo entrevistó a él y al Dr. Pérez en el IPK, en la Habana.

Her passion for the “new world of informatics” led engineer Niurka Carlos to study computer sciences and digital systems, and her passion for health led her to join the embryo of Cuba’s Immunoassay Center in 1982 right after graduation from university in 1987, becoming one of the Center’s founders when it was launched that same year. First specializing in software, Ms Carlos was promoted to department chief, the Center’s management team and later to deputy director. She has headed the Center since 2014, leading implementation of research, production and marketing of diagnostic tools for the national health system and export. Today, the Center is expanding its horizons into chronic diseases that have become the main causes of illness and death in Cuba and are afflicting low- and middle-income countries at alarming rates as part of the world’s epidemiological transition. MEDICC Review spoke with Ms Carlos about the history, results, challenges and new frontiers of the Center in its 30th anniversary year.

El trasplante de órganos y tejidos ofrece una posibilidad de salvación a pacientes en todo el mundo. Pero el acceso a este último recurso de tratamiento está limitado por muchas barreras: el acceso a la atención médica en primer lugar, y en particular a estos procedimientos de alta tecnología, limitado por las
desigualdades geográficas, de género, raza u origen étnico o de nivel económico, entre otros. El acceso, además, depende de la organización del sistema de salud; sus recursos humanos y materiales; las normas culturales y las creencias religiosas; la corrupción y el tráfi co de órganos; y el nivel de educación pública,
cohesión social y voluntad política de los gobiernos.
Tomados en conjunto, estos factores hacen que la donación y el trasplante de órganos sea uno de los problemas de salud más complejos que enfrentan los países, incluyendo a Cuba. Y la cadena que conduce a resultados exitosos es larga y frágil y está plagada de dilemas éticos, legales y médicos. El nefrólogo Alexander Mármol, director de la Oficina Nacional Coordinadora de Donación y Trasplantes (ONCDT) del Ministerio de Salud Pública, señala que los donantes representan el eslabón primero y esencial. “Sin los donantes, no puede haber ningún trasplante. Usted puede tener el mejor equipo quirúrgico del mundo, pero no puede fabricar un órgano. Los donantes y sus familias son los verdaderos héroes”.

After leaving Chile during the Pinochet era, Dr Morales studied economics, health administration and international health at the University of Montreal. But his baptism in the field came in Haiti, where he was first PAHO advisor to the health ministry, and then for five years was responsible for human resources and health economics in the PAHO offices in the capital of Port-au-Prince. He was at his post during the flooding in Gonaïves, five hurricanes, the 2010 earthquake and the ensuing cholera epidemic—doubtless the most dramatic and complex times for the country’s health in recent history. Before becoming the PAHO/WHO Representative in Cuba in 2015, he was Regional Advisor in Financing and Health Economics based in Washington, DC. In that role, he plunged into the often thorny debates about just how far governments of the Americas were willing to go towards achieving universal health—universal coverage plus universal access. The result was a historic resolution passed in late 2014 by PAHO’s Directing Council (CD53.R14 Strategy for Universal Access to Health and Universal Health Coverage). Dr Morales talks about the process, the outcomes… and the road ahead.

Organ and tissue transplantation extends a lifeline to patients across the globe. But access to this therapy of last resort is restricted by many barriers: access to health care in the first place, particularly to such high-tech procedures, limited by inequities in geography, gender, race/ethnicity or economic status, among others. Access is further influenced by health system organization; its human and material resources; cultural norms and religious beliefs; corruption and organ trafficking; and degree of public education, social cohesion and political will of governments.

El Dr. Aja es, él mismo, un producto de los flujos y reflujos de la migración cubana. Su padre, hijo de inmigrantes libaneses en Cuba, estudió medicina y emigró a Nueva York. Allí conoció a la madre de Antonio, una trabajadora textil e hija de una familia de emigrantes pobres cubanos. La joven pareja se mudó a Tampa, Florida —siguiendo el patrón de asentamiento de los cubanos en Estados Unidos en aquella época— lugar donde Antonio nació en 1953. Toda la familia regresó después a Cuba, en medio de la lucha contra Batista en la década de 1950. Ellos se quedaron, pero sus familiares andan dispersos por el mundo… como ocurre hoy con muchas familias cubanas. El Dr. Aja dice que su propia historia lo motivó a explorar la relación entre las familias, la demografía y la migración, un tema complejo que ha estudiado por un cuarto de siglo.

En la más amplia concepción de salud y sociedad, los editores de MEDICC Review pidieron al Dr. Aja compartir sus visiones sobre estos años de investigación y su experiencia.

Dr Aja (pronounced á-ha) himself, is a product of the ebbs and flows of Cuban migration. His father, son of Lebanese merchant immigrants to Cuba, later studied medicine and emigrated to New York. There he met Antonio’s mother, a garment worker and daughter in a poor family of Cuban émigrés. The young couple moved to Tampa, Florida—following a pattern of settlement for Cubans in the USA at the time—where Antonio was born in 1953. The whole family later returned to Cuba, amidst the 1950s rebellion against Batista. They stayed, but relatives are still sprinkled abroad…as they are today for many Cuban families. Dr Aja, says his own history is part of what prompted him to explore the relation of families, demography and migration, the complex subject he has studied for a quarter century.

Under the broader scope of health and society, MEDICC Review editors asked Dr. Aja to share insights from his years of research and experience.

Tramping through the Himalayan snows to treat patients after the 2005 Pakistan earthquake, internist Félix Báez could never have imagined he would be on the front lines of Ebola in Sierra Leone nine years later….much less that he would contract the deadly virus, live to tell the story and also to return to his team in Africa to continue the fight. At his side in the Geneva University Hospital, where he was airlifted, was Dr Jorge Pérez, today director of Cuba’s Pedro Kourí Tropical Medicine Institute (IPK), but best known as “Cuba’s AIDS doctor.” Times have changed for both physicians, and Ebola is first on their minds as it rages on.

At this writing, while there is cautious optimism in Liberia, the epidemic is not yet under control. Ebola has already infected nearly 22,000 people, taken over 8600 lives; Sierra Leone is one of the countries hardest hit. Among the sick and dying have been too many local health workers: 103 of the 138 infected, at last count.

The first to sound the global alarm was Doctors Without Borders, which, like Cuba, already had health professionals on the ground in Africa; they were joined by many more, and Cuba was the country that offered the most assistance once WHO called for nations to step up with funds and, most importantly, human resources.

Cuba sent 256 volunteers, all with significant international emergency experience: 38 to Guinea, 53 to Liberia and 165 to Sierra Leone. And more wait in the wings, specially-trained disaster medical workers who have already received their first round of Ebola courses at IPK.

These Cuban and other international volunteers are bringing patients back from the brink of death, assisting national health workers and community educators. And people like Jorge Pérez are working to get to the bottom of Ebola to help prevent its spread throughout Africa and to other parts of the world.

But to keep an epidemic like this from happening again, it will take more, much more. Not only could the global community have done a better job this time around. But as Jim Kim, President of the World Bank admonished, Ebola didn’t start with disease, but rather with historic inequalities, the virus festering within health systems barely able to function. A lesson for us all.

Hours before Dr Báez’s return to Sierra Leone—where he is now—MEDICC Review interviewed him and Dr Pérez at IPK in Havana.

A los 43 años, la Dra. Beatriz Marcheco es una mujer con múltiples responsabilidades: dirige el Centro Nacional de Genética Médica en La Habana, que es Centro Colaborador de la OPS/OMS para el Desarrollo de Enfoques Genéticos en la Promoción de Salud; preside el Grupo Nacional de Genética Clínica y el consejo editorial de la Revista Cubana de Genética Comunitaria; y es profesora titular de la Universidad de Ciencias Médicas de La Habana.

Pero fue una experiencia personal la que incitó su pasión por la genética humana: casi al concluir sus estudios de medicina, supo que su madre padecía el Síndrome de Usher, una enfermedad genética rara que conduce a la pérdida progresiva de la visión y la audición. Conoció así, de primera mano, las consecuencias en las familias de la presencia de enfermedades genéticas incurables. “Esto se convirtió en un desafío para mí”, dice, “prevenir, curar, o por lo menos ayudar a estas personas para que transiten por la vida con el menor trauma posible”.

Desde que se especializó en genética clínica, la Dra. Marcheco ha participado en importantes esfuerzos para aplicar las investigaciones en este campo a los problemas de salud de pacientes individuales y a la salud poblacional —desde un estudio pionero en Cuba relacionado con las discapacidades, realizado de puerta en puerta, hasta la creación de un registro nacional de gemelos y, por último, la búsqueda de los antepasados genéticos de once millones de cubanos. Este último es el tema de un reciente artículo de su grupo en PLoS Genetics (Cuba: Exploring the History and Admixture and the Genetic Basis of Pigmentation Using Autosomal and Uniparental Markers, publicado el 24 de julio, 2014, DOI: 10.1371/journal.pgen.100448) y también de la conversación de la Dra. Marcheco con MEDICC Review.

At 43, Dr Beatriz Marcheco is a busy woman: she directs the National Medical Genetics Center in Havana, a PAHO/WHO Collaborating Center for Developing Genetic Approaches for Health Promotion; chairs the National Expert Group in Clinical Genetics and the editorial board of the Revista Cubana de Genética Comunitaria; and is full professor at the Medical University of Havana.

Yet, her passion for human genetics was ignited by personal experience: towards the end of medical school, she realized her mother was suffering from Usher Syndrome, a rare genetic disorder leading to progressive hearing and vision loss. She came to know firsthand the devastation brought upon families by untreatable genetic diseases. “So it became a challenge for me,” she says, “to prevent, to cure, or at least to help these people make their way through life with as little trauma as possible.”

Since specializing in clinical genetics, Dr. Marcheco has been involved in major efforts to apply research in the field to individual patients and population health—from Cuba’s groundbreaking door-to-door study on disabilities, to establishment of a national twin registry, and finally the search for the genetic ancestors of 11 million Cubans. This last is the subject of her group’s recent article in PLOS Genetics (Cuba: Exploring the History and Admixture and the Genetic Basis of Pigmentation Using Autosomal and Uniparental Markers, published: July 24, 2014, DOI: 10.1371/journal.pgen.100448) and also of Dr Marcheco’s conversation with MEDICC Review.

Cuba is the only country I know to erect a monument to the egg….and so it should. Located on Havana’s Fifth Avenue, the simple sculpture pays homage to the salva vida—literally the life saver of many a Cuban family, particularly in the 1990s. Those were the worst years of what was euphemistically called the “Special Period,” when the economy careened ever downward, reeling from the loss of 85% of Cuba’s aid and trade in the post-Soviet era.

He sips mate, the bitter brew of his native Uruguay as he converses at PAHO’s offices in Havana. Yet, he already feels at home here, says Dr Di Fabio, who took up his post in July of 2011. This is not surprising, since his connection to Cuban health care and research predates his arrival by two decades. In 1992–93, he worked on the Americas’ vaccine system (SIREVA) for PAHO and became involved in monitoring cooperation in vaccine regulatory issues, quality and production. From that period emerged one of Latin America’s great achievements: Vicente Vérez Bencomo’s development at the University of Havana of the world’s first Haemophilus influenzae type b (Hib) synthetic-antigen vaccine. Dr Di Fabio came to Cuba often to follow up on the vaccine’s regulatory process, production, and quality control for PAHO.

Later, he continued working on access to vaccine technology at PAHO headquarters in Washington, DC. It’s a journey that has taken him not only far from home, but also from his professional beginnings in Vancouver, Canada, as a PhD in organic chemistry. But it’s Dr Di Fabio’s “chemistry” with Cuba that is the subject of our conversation, his openness incongruent with the stiff antique furniture in his upstairs PAHO quarters—which nevertheless offer one of the best tree-top views of the Cuban capital.

Medicine, social conditions, culture and politics are inextricably bound as determinants of health and wellbeing. In Cuba, perhaps this is nowhere more evident than in the arduous struggle to consider non-discriminatory analysis of gender-sensitive components as fundamental to population health, medical practice and research; national policy; and above all, public consciousness. Among the standard-bearers of this cause is Mariela Castro, psychologist and educator with a master’s degree in sexuality, who directs the National Sex Education Center (CENESEX), its journal Sexologia y Sociedad, and the National Commission for Comprehensive Attention to Transsexual People. The Center’s work is at the vortex of national polemics on sexuality, approaches to sex education and health, and respect for the human rights of people of differing sexual orientations and gender identities.

The daughter of President Raúl Castro and the late Vilma Espín—who, as founder and leader of the Federation of Cuban Women, pioneered the defense of both women and homosexuals—Mariela Castro nevertheless speaks with her own voice in national as well as international debates. MEDICC Review talked with her about the range of issues that link gender to WHO’s broad definition of health as the highest level of physical and mental wellbeing.