Improving health systems’ management, efficiency and quality can be the source of improved population health. But only if the systems themselves are equity-based. If drug and technology innovation, streamlined patient care and enhanced prevention simply reflect societal divisions and generate results for the few, then such advances can only worsen health disparities. Hence, the title of our editorial, which begs the question: better management, efficiency and quality towards what end? Towards better population as well as individual health, towards health equity.

“Transforming education to strengthen health systems in an interdependent world” is the subtitle to a report by a global commission on health professional education, Health Professionals for a New Century (HPNC). The report aspires to do for health professional education in this century what Flexner did for medical education in the last—spark a revolution.[1] And indeed a necessary one if we are to see global health equity in practice, not simply in print.

Social scientists have long held that gender differs from biological sex indicated by an ‘M’ or ‘F’ written on a birth certificate, since it encompasses constructs and roles assigned by different societies to each sex. The nature of gender and its effects on opportunities and outcomes in every social arena—health included—have fuelled academic and political debates and been the subject of four major UN conferences.

Gender has been recognized as a primary determinant of health practically from the minute the phrase was coined, but the 2012 World Development Report: Gender Equality and Development describes uneven progress over the past 25 years in women’s status and opportunities, both geographically and by indicator. It cites, for example, persisting gender wage gaps but an acceleration in global narrowing of the gender education gap, with some regions, countries or subpopulations lagging behind. At the same time, disparities are emerging that disadvantage men and boys, such as higher secondary school dropout and repetition rates.

Cubans are known the world over for their inventiveness, doubtless borne of necessity, but also informed by higher educational levels than in many developing countries. In this issue, we present innovative approaches—both practical and radical, both of proven benefit and still to be validated—from the front lines of Cuban population health and clinical research.

Fourteen years before the Lalonde Report, Cuba’s emerging public health model contributed to what we would now call a multisector strategy to address the social and economic determinants of health. Its three prongs were a rural medical program, sending newly graduated MDs to address the needs of sorely underserved rural and remote communities; an ambitious campaign to eradicate illiteracy, a critical determinant of health and wellbeing; and land reform, to tackle the fundamental issue of rural poverty.

These words from Dr Martin Luther King, Jr. ring true in today’s global quest for equity and a greater measure of social justice in every field, no less so when it comes to disease prevention and access to health care itself. The time is long past when chronic non-communicable diseases (NCDs) were a problem mainly for the well-to-do and the industrialized nations. With longer life expectancies in most countries and the globalization of “Western” diets and sedentarism, the main burden of disease and death from these conditions is falling on already-disadvantaged developing countries and poor communities everywhere. Over 80% of chronic disease deaths occur in low- and middle-income countries.[1]

Since our last issue, the world has lost two eminent public health researchers and practitioners, both of whose work has been inspirational to us at MEDICC Review. Dr Gustavo Kourí Flores was a Cuban physician who directed the Pedro Kourí Tropical Medicine Institute in Havana, a WHO Collaborating Center, for more than three decades. Dr Barbara Starfield was a leader in research on health inequalities and a powerful advocate for primary health care. Both will continue to influence public health through their legacies in research, teaching, and practice.

Thirty years ago, in June of 1981, the first report of what came to be called AIDS was published; ten years ago, the UN General Assembly adopted the Declaration of Commitment on HIV/AIDS; and five years ago, the same body issued the Political Declaration on HIV/AIDS. This year, UN member states will take stock of what has been accomplished and decide the shape of the future global response to the modern world’s gravest infectious pandemic.

A heartening turn took place when global incidence began falling in 1999, and many thought the spread of the disease was waning at last. The introduction of antiretroviral treatment provided new hope to those already infected. Today there are 33.3 million people living with AIDS, 27% more than in 1999. Some 56 countries have stabilized or reduced new infections by more than one quarter. That is the good news.

A sight for sore eyes. Keep your eye on the ball. Left in the dark. Look before you leap. Seeing is believing. Watch your step…Our language abounds in visual metaphors, reflecting the importance of vision for our interactions with the environment, for our ability to understand, appreciate, and negotiate life itself.

In fact, over 80% of our sensory input is visual, the starting place for what may be the best example of the bio-psycho-social paradigm for defining health and illness. Articles in this issue of MEDICC Review range through that complex spectrum, devoting pages to vision loss, surgical correction and rehabilitation; development and social inclusion of visually disabled persons; and the enigmas of vision-related epidemics in Cuba.

In this world of daunting disparities, no one doubts that transformational change to improve population health, expand health equity and build better-performing health systems is a tough job. Certainly no undertaking for the comfortable or faint-hearted.

In this issue, we present the work, perspectives and research of some of Cuba’s “uncomfortable”, who are challenging the boundaries of science and society to generate new policies and innovative practices aimed at better health. The starting point is a critique of the Cuban capital itself, home to 2.1 million people, one of the fastest-aging populations in the Americas. Architect and urban planner Miguel Coyula argues that the city he calls home is unprepared to ensure a healthy quality of life for the 60-year-old-plus generation, already nearly 20% of its inhabitants (Havana: Aging in an Aging City). He calls for studies to reveal policy alternatives that could comprehensively address the multiple needs and rights of the capital’s older adults.

In 1990, a seminal report from the Commission on Health Research for Development pointed to the gross imbalance between the magnitude of diseases affecting the world’s poor majority and the meager funds spent on research to fight them. Responding to growing momentum, in 1997 the Global Forum for Health Research was founded to address this skewed research agenda. Fast-forwarding to 2009, the Geneva-based organization held its 13th meeting in Havana on the theme Innovating for the Health of All, inspiring collaboration between MEDICC Review and Forum organizers for an issue dedicated to research, innovation and global health equity.

This MEDICC Review was to focus exclusively on child and adolescent health in Cuba, re-introducing a theme explored in several earlier issues of the journal. However, the January earthquake in Haiti—its human toll, medical relief efforts and health system recovery—has led us to broader considerations and coverage.

Senior Editor Conner Gorry was dispatched to Port-au-Prince in February, where she spent the next month among Cuban and Latin American health professionals serving in Cuba’s Henry Reeve Emergency Medical Contingent. Leaving her tent in the mornings to hitch rides to hospitals, health posts and resettlement camps, she covered the work of these clinicians, surgeons, epidemiologists, psychologists, health educators and rehabilitation specialists—including young Haitian physicians, graduates of Cuba’s Latin American Medical School. (Once the Earth Stood Still: Cuban Rehabilitation Services in Haiti).

A number of global crises usher in the second decade of the new millennium this month: climate change, food security and health among them. Exacerbating each is the world’s economic recession that thus far shows little reprieve, especially for poorer nations. In this environment, the logical demand is being raised for science to pay more […]

When it comes to nutrition, like most middle-income countries, Cuba is equally haunted by shadows of an undernourished past and forebodings of an overweight future. This dilemma is the country-level expression of a tough global reality: the world’s empty stomachs and empty calories result from the same skewed constellation of international economic and trade policies. Speaking of the current and unprecedented food, fuel, climate and financial crises, World Health Organization (WHO) Director-General Margaret Chan comments: “…they are the result of massive failures in the international systems that govern the way nations and their populations interact. In short: they are the result of bad policies…(in which) economic interests trump health concerns time and time again.”[1]

There are no face masks against cancer. No trail of cases to hunt down, no one set of symptoms, no media blitz, no ready cure. Epi early warning systems, however fine-tuned and high-tech, are no match for this disease, which affects 12 million more people each year and kills nearly 8 million.

The problem with cancer, as with all chronic diseases in the global pandemic, is that it challenges all of us—individuals, professionals, health systems, governments and societies at large—to make fundamental changes. Why? Because at the heart of cancer prevention and control, repeated in forum after forum, is achieving healthier living. And for a world in which poorer countries and people will soon account for three-fourths of cancer deaths, the heart of the matter is also achieving healthier living for all.

The fastest, highest, strongest, the perfect rhythm or spectacular play—in essence, the beauty and thrill of sports. Yet, our vision of sports medicine is usually circumscribed–as on our cover—to the team doctor treating a player’s injury on the field. The inside pages of this issue take a deeper look and bring to mind that while sports themselves generate lessons for life and society, sports medicine can offer vital lessons for approaches to health care.

The theme of this issue of MEDICC Review—Medical Technology and Health Equity—mirrors that of the previous one—Medical Education for Health Equity. This is no coincidence. As Charles Boelen’s Viewpoint in the earlier issue suggests, socially accountable medical training programs are essential to achieving health equity but are not enough; it takes a whole health system built around a shared commitment to providing quality care for all. This implies integrating people and tools, with policies that encourage communication and knowledge sharing among researchers, practitioners and the public at large and that facilitate technology transfer across borders and institutions.