In this double issue, MEDICC Review celebrates a cornucopia of achievements, but in an atmosphere of uncertainty about the future of US health care and about US–Cuba relations.
On the celebration front…Dr Tedros Adhanom Ghebreyesus (Ethiopia) became WHO’s first African Director-General on July 3. In his address to WHO staff, Dr Tedros (as he prefers) emphasized that “universal health coverage…is a human rights issue. And the responsibility of national governments. It’s not only a technical matter but even more so a political one. Countries should compare their results to their peers and learn from each other.” This must sit painfully with many Americans, who are protesting in record numbers attempts by some in Congress to dismantle their health coverage and leave millions without care altogether. In this context, it is ironic that the Commonwealth Fund ranks the USA last among 11 wealthy countries in health system performance,[1] and health system efficiency ranks well below Cuba and some other poorer countries.[2]
Whether or not the so-called curse, “May you live in interesting times” is apocryphal, we have to acknowledge that we do indeed live in interesting times. It has been only three months since the October 2016 issue of MEDICC Review, but the changes since—in many directions—have been head-spinning.
For starters, scientists at Roswell Park Cancer Institute have launched a clinical trial of CIMAvax, the therapeutic lung cancer vaccine developed at Cuba’s Molecular Immunology Center, surely a win–win for the citizens of both countries. The vaccine, intended to lengthen life and restore quality of life to people suffering from non-small cell lung cancer, has already been used for thousands of patients in Cuba and abroad. Cuban researchers say that the aim of such cancer immunotherapies is to use them in combination with others to convert cancer from a life-threatening condition to a chronic disease.
Ushered in with the rampage of Hurricane Matthew, later days brightened in this month that has often been harbinger of both good and bad news for Cuba and the world.
Hurricane Matthew ripped through Eastern Cuba, devastating the historic town of Baracoa (Cuba’s first capital, founded in 1511) and the village of Maisí, where the morning sun first rises over Cuban territory. Wind and flood leveled hundreds of homes, brought down the power grid and destroyed crops. Yet there was no loss of human life, unlike in neighboring Haiti and other countries in Matthew’s path, and unlike in Cuba in 1963, when Hurricane Flora caused more than 1200 deaths. In Haiti, efforts of health workers—including hundreds of Haitian graduates from Cuba’s Latin American Medical School and 600 Cuban health professionals already there—were bolstered by dozens of specially trained Cuban disaster medical personnel in the wake of the storm.
Cuban advances in biotech have made headlines, particularly since the US–Cuba rapprochement and signing of the historic memorandum of understanding between the US Department of Health and Human Services and Cuba’s Ministry of Public Health in June. Some 34 Cuban institutions with 22,000 employees are the backbone of a biotech industry that dates to the early 1980s, obtaining novel products that have sparked interest among potential global partners. While a number of these Cuban products are registered in various countries, their testing in the USA remains ensnared in the red tape of embargo laws that tend to make investors skittish and thus delay, if not curtail, joint research and clinical trial applications to the FDA.
President Obama’s Havana visit in March was both product and symbol of improved Cuba–US relations following renewed diplomatic relations and opening of embassies last year. Encouraging too was the first high-level visit to Washington DC by Cuban Ministry of Public Health leaders, headed by First Deputy Minister José Angel Portal (March 28–April 1). All are promising developments that could open the door to bilateral cooperation.
In the field of health, US people may stand to benefit as much as Cubans. As one of our Viewpoints in this issue suggests, Cuban biotech innovations are increasingly in use and in demand worldwide, but have had a hard time overcoming extra hurdles in the USA, erected by the US Department of the Treasury’s Office of Foreign Assets Control (OFAC), not the FDA. One such innovation is Heberprot-P, a medication for diabetic foot ulcers that clinical trials elsewhere have shown reduces relative risk of amputation by 70%, a dramatic figure if you consider the some 73,000 amputations in the United States annually. As diabetes and its costs rise throughout the USA and worldwide—“beat diabetes” the theme of this year’s World Health Day—it seems reasonable to allow such a product access to the normal FDA regulatory process, even to fast-track it.
It is no news to anyone that health transcends national borders, driven by cross-border movement of vectors, populations, health professionals, climate, even policy trends. There is an increasing recognition that it is, in fact, a small world: we are affected by and affect what happens to our neighbors, whether they live around the corner or on the other side of the globe.
This conception underpins the shift from the term international health to global health in policy discussions. The new terminology reflects change across several dimensions:
- from an approach in which there is one medicine for the developed world and another for developing countries, to an appreciation that we all have a stake in one another’s wellbeing;
- from a primarily biomedical focus on treatment to a more multidisciplinary, population health focus taking into consideration a range of interventions to improve health and well-being, including the social and environmental determinants of health; and
- from a vertical bilateral-aid approach focused on specific diseases, to systems and ecological approaches addressing the complexities of health, involving multiple partnerships.
This issue of MEDICC Review appears in the wake of a media splash on the reopening of the Cuban and US embassies in Washington and Havana, signaling the renewal of full diplomatic relations between the two governments. Although the US embargo is still law and one of the thorniest bilateral issues remaining, the Obama administration’s bold opening towards Cuba is being echoed in the chambers of Senate committees, calling for an end to the policy in place since 1962. Meanwhile, people from the United States have begun to travel to Cuba in droves, and for the first time in many years, we perceive real hope that cooperation may replace hostility—at least in the sectors that most matter to ordinary people in both nations.
It is ironic that MEDICC Review‘s theme issue on environment, climate change and health goes to press in April, one of the hottest on record in Cuba. Sunday, April 26 was one of the hottest days in the past five decades—and this in what is usually considered one of the country’s cooler months, with summer officially beginning in June. If this is April, Cubans are saying, what will happen in July?!
April is also, of course, the month we celebrate Earth Day, which acquires particular relevance this year, when world governments must decide on new sustainable development goals and create a framework to ensure financial support for a global sustainable development agenda. In her Earth Day remarks, Mary Robinson—former president of Ireland and UN High Commissioner for Human Rights, now UN Special Envoy on Climate Change—said that 2015 is a critical year, one in which greenhouse emissions must stay “within budget” to avoid mean temperatures rising 2 °C above preindustrial levels. She emphasized the concept of climate justice, meaning an equitable sharing of the benefits and burdens of preventing climate change and mitigating its impacts. Particularly, wealthier countries whose growth has depended mainly on fossil fuels must move quickly to a sustainable development model, while committing resources to help middle- and low-income countries transition to zero-carbon development.[1]
Women and children first! is a phrase rather infamously associated with the sinking Titanic. Although without basis in maritime law, it reflects an ethical imperative to protect those who historically are perceived as the most vulnerable in times of peril, diametrically opposed to the skewed survival-of-the-fittest posture. (Women are of course as fit or fitter than men, but that would take another editorial.)
Global commitment to protecting maternal and child health (MCH) is integral to public health, and to sustainable social and economic development as well. The World Bank estimates that the global economic burden of disease could be reduced by up to 30% with optimal implementation of half a dozen cost-effective and affordable public health and clinical services: family planning, antenatal and delivery care, immunization, integrated management of childhood illness and HIV/AIDS prevention. The UN recognized MCH as integral to its Millennium Development Goals. Then last year, the Open Working Group on Sustainable Development Goals post-2015 set specific MCH targets for the world: Goal 3 (Ensure healthy lives and promote wellbeing for all at all ages) includes ending preventable neonatal and under-5 mortality by 2030 and reducing the global maternal mortality ratio to 70 per 100,000 live births (Cuba’s was 38.9 in 2013).
Describing this double issue of MEDICC Review could be an exercise for a first-year philosophy course in logic. It’s not about “cancer and genetics” in Cuba. It’s about cancer in Cuba and about genetics in Cuba, not about exploring relationships between them.
Nevertheless, while the marriage of the two themes was fortuitous, in that the two had long been scheduled for the journal in 2014, there is a certain felicity to their sharing an issue. To date, the outstanding accomplishments of genetics have been most helpful for conditions occurring at the beginning of life and cancer is largely (though not exclusively) a disease related to aging. But the two are intrinsically connected: Although only a few of the more than 100 different diseases grouped under the term cancer are known to be hereditary, every cancer begins with a mutation in one or more genes, whether the mutation is inherited, due to an exposure, or is simply a random error in the millions of cell divisions that are part and parcel of cellular reproduction. Our cover image, a stained-glass window by Cuban artist Rosa María de la Terga at Cuba’s National Medical Genetics Center, illustrates the elegance of the DNA molecule, the intricate key to life.
When chronic kidney disease (CKD) rates began to climb in poor agricultural communities in Central America and elsewhere at least a decade ago, no one could have predicted the devastation wrought since then by what appears to be a new form of nephropathy. An epidemic that in a country such as El Salvador has catapulted end-stage renal disease to third place among causes of hospital deaths, first place among men.
Termed alternately CKD of nontraditional causes, CKD of unknown etiology, agricultural nephropathy, chronic agrochemical nephropathy, Mesoamerican epidemic nephropathy, and CKD of uncertain etiology—its effects are the same and its characterization similar in the countries where it has emerged. Most often described histopathologically as chronic tubulointerstitial nephritis, this CKD has thus far been studied in El Salvador, Nicaragua, Costa Rica, Mexico, Sri Lanka, Egypt and India. We prefer CKD of uncertain etiology (CKDu), since initial research findings point to multifactorial causation in nearly all cases.
In 2013 Cuba recorded its lowest infant mortality rate ever, 4.2 deaths per thousand live births, lower than anywhere else in the Americas, even the developed North. US health researchers have visited Cuba to try to understand how such an impressive outcome is possible in a grievously resource-limited setting.[1]
Part of the answer lies in Cuba’s universally accessible health care with a focus on primary care and prevention. This year marks the 30th anniversary of the national Family Doctor-and-Nurse Program, which has helped Cuba achieve enviably low rates of low birth weight and infant mortality, while—not incidentally—reducing emergency room visits.
Our issue coincides with World Mental Health Day, October 10. This year’s day was devoted to the crisis of depression, which affects more than 350 million people across the age spectrum and around the world. In many countries, the vast majority of people afflicted receive no treatment at all.
In fact, a recent report on mental health care in the United Kingdom by the Royal College of Psychiatrists found a shocking gap in access to care for mental compared to physical health problems: only 24% of adults with common mental disorders were receiving treatment. And this is in a developed country with a national health system, where it would be unthinkable to find three quarters of people with diabetes, heart disease or cancer left untreated. The question immediately arises: what happens in the developing world and communities with far scarcer resources, or where access to services is largely left to the vagaries of the market? The answer hardly needs statistics: pitifully little. Poor people’s mental health is simply not on the agenda, while private practitioners do fine with well-to-do clients.
A growing global movement argues for health to take center stage in the post-2015 sustainable human development agenda, building on the Millennium Development Goals and improving measurement of outcomes and equity. Considered key is the urgent need to effectively stem chronic noncommunicable diseases (NCDs). The reasoning is straightforward and yet addresses the interactive complexities of NCD impact and the potential synergies to reduce it: NCDs constitute the most important, if until recently neglected, pandemic of our era. They accounted for over 65% of global deaths and 54% of the global disease burden in 2010.[1,2] Such a negative “contribution” —including the sequelae of disability and alarming costs of treatment for multimorbidities associated with aging populations worldwide—jeopardizes sustainable human development.
In the 1978 Alma-Ata Declaration, developing countries threw down the gauntlet to the world’s richer nations: it was time to recognize health care as a fundamental human right, implemented first and foremost by adopting comprehensive, universal primary health care models. The fiery debates came on the heels of a decade of decolonization and the Non-Aligned Movement’s call for a New World Economic Order. The ensuing years, however, brought the unravelling of such an ambitious agenda, with neoliberal economic policies taking apart primary health care piece-by-piece, wrapping the remnants in “minimum” packages for specific population groups. The drive for health equity as a social policy faltered—the comprehensive, accessible, intersectoral, community-engaged, population-based and patient-centered principles of Alma-Ata all but lost.
Diabetes is the paradigmatic chronic disease of our time: tragically disabling with devastating complications, and increasingly prevalent—but often approaching silently as a shark. Nearly half of diabetics are unaware of their condition, although the International Diabetes Federation estimates 366 million people worldwide suffer from the disease and it caused 4.6 million deaths in 2011.[1] Diabetes apparently chooses its victims at random, but this is not so. They are mainly people already plagued by unhealthy lifestyles, including poor nutritional habits and inactivity, with the resulting byproducts of excess weight gain and obesity. They are also predominantly people who come from developing countries or disadvantaged population groups in developed nations: by 2030, says the Federation, developing countries will be the home of 82.5% of the globe’s diabetics.
