El neonatólogo Dr. Fernando Domínguez trabajó dos años en un remoto municipio de la provincia cubana de Guantánamo después de graduarse de la Facultad de Medicina en 1973. Dando continuidad a su compromiso con las poblaciones vulnerables, se unió al equipo médico de Cuba en la República Democrática del Congo, donde trabajó como médico de familia en la asistencia a neonatos y niños. Después de regresar a Cuba, terminó su residencia en Pediatría y más tarde se convirtió en jefe del Departamento de Neurodesarrollo en el Hospital Universitario de Maternidad Ramón González Coro en La Habana, donde ha trabajado durante más de tres décadas.

El Dr. Domínguez obtuvo un doctorado en ciencias médicas, y desde 1995 es miembro de la junta directiva de la Sociedad Cubana de Pediatría, de la que fue presidente desde 2005 hasta 2011. También es miembro de la Comisión Nacional de Bioética del Ministerio de Salud Pública; Presidente del Consejo Científico de la Facultad de Medicina Manuel Fajardo; pertenece al Comité Ejecutivo de la Asociación Latinoamericana de Pediatría; y es miembro de la Comisión Permanente de la Asociación Internacional de Pediatría (AIP). Desde 2010, ha formado parte de la Comisión de Salud Ambiental para el Niño de la AIP y es Editor Jefe de la sección pediátrica de Infomed, el portal nacional de salud de Cuba.

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.

Call them intrepid trailblazers or just plain stubborn: over 200 US students, mainly from under-represented minorities and low-income families, decided they would become the doctors needed by their communities, and that Cuba’s Latin American Medical School (ELAM) would prepare them for the job.

In doing so, they accepted a host of challenges, not the least of which was studying in a country lauded for its population health indicators, but vilified for decades by their home government. Under President George W. Bush, even their enrollment required intercession from then Secretary of State Colin Powell and the Congressional Black Caucus, whose members represent districts with some of the poorest health indicators in the United States. Once they were accepted by ELAM, with its own hefty academic requirements, it was unclear if they could cope with living in Cuba, a poor country with limited resources. And then came the challenge of passing the US Medical Licensing Examination (USMLE), required of all US medical students to secure residency placements.

Added to these hurdles was another big question: would they actually serve in remote, inner-city and poor communities or just take the free medical education and abandon the social objectives cultivated by their alma mater?

ELAM’s concept is a simple but bold one: that providing free medical education to bright students driven to become doctors, but without the financial means to do so, will motivate them to return to serve in communities like their own. They spend six years learning basic sciences, clinical medicine and public health. Since the first graduation in 2005, ELAM has trained nearly 25,000 doctors—most women and many of them indigenous—from 84 countries, including the USA.

A decade after the first US graduate received his diploma from ELAM, 113 have followed. While most (especially recent) grads are still finishing their USMLE exams, 40% of the total are already in residencies or have completed them: of these, 90% have chosen to practice in three main primary care specialties—family medicine (61%), internal medicine (23%) and pediatrics (6%). Of US graduates already practicing, 65% work in Health Professional Shortage Areas (HPSAs) and/or Medically Underserved Areas (MUAs). The success of these doctors also helps destigmatize the Cuban program; US foreign medical graduates are often viewed as substandard, the assumption being that they studied abroad because they couldn’t get accepted anywhere else. But often, as in the case of ELAM-trained doctors, US medical education poses a financial, not intellectual, barrier to their training.

The Medical University of Havana is one of 14 medical schools in Cuba. At its July graduation ceremonies, diplomas were handed to over 1200 doctors from Cuba, Central and South America, the Caribbean, Africa, and Asia—including ELAM graduates, among them 21 from the United States.

MEDICC Review interviewed several US ELAM graduates as they readied to leave for home—Wyoming, Louisiana, Pennsylvania, Texas, Florida and elsewhere. They talked candidly about the advantages and challenges of studying medicine in Cuba, the licensing process for practice in the United States, and their plans for the future.

The US National Institutes of Health predict climate change will cause an additional 250,000 deaths between 2030 and 2050, with damages to health costing US$2–$4 billion by 2030. Although much debate still surrounds climate change, island ecosystems—such as Cuba’s—in the developing world are arguably among the most vulnerable contexts in which to confront climate variability. Beginning in the 1990s, Cuba launched research to develop the evidence base, set policy priorities, and design mitigation and adaptation actions specifically to address climate change and its effects on health.

Two researchers at the forefront of this interdisciplinary, intersectoral effort are epidemiologist Dr Guillermo Mesa, who directed design and implementation of the nationwide strategy for disaster risk reduction in the Cuban public health system as founding director of the Latin American Center for Disaster Medicine (CLAMED) and now heads the Disasters and Health department at the National School of Public Health; and Dr Paulo Ortiz, a biostatistician and economist at the Cuban Meteorology Institute’s Climate Center (CENCLIM), who leads the research on Cuba’s Climate and Health project and is advisor on climate change and health for the UN Economic Commission for Latin America and the Caribbean (ECLAC).

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.

Neonatologist Dr Fernando Domínguez served two years in a remote municipality of Cuba’s Guantánamo Province upon graduation from medical school in 1973. Continuing his commitment to vulnerable populations, he joined the Cuban team in the Democratic Republic of the Congo, serving as a family doctor attending neonates and children. After returning to Cuba, he completed his pediatric residency and later became head of the neurodevelopment department at Havana’s Ramón González Coro University Maternity Hospital, where he has worked for over three decades.

Dr Domínguez holds a doctorate in medical sciences, and since 1995 has served on the board of the Cuban Society of Pediatrics, where he was President from 2005-2011. He is also a member of the Ministry of Public Health’s National Bioethics Commission; President of the Scientific Council of the Manuel Fajardo Medical School; on the Executive Board of the Latin American Association of Pediatrics; and a member of the Permanent Commission of the International Pediatric Association (IPA). Since 2010, he has served on IPA’s Commission for Child Environmental Health and is the Editor-in-Chief of the pediatric section of Infomed, Cuba’s national health portal.

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.

Por más de 40 años, él ha realizado una de los trabajos más difíciles en medicina; 4 000 de sus pacientes podrían haber sido descartados como “causas perdidas”. Sin embargo, él irradia optimismo; sus historias y experiencias reflejan una creencia en el potencial humano para cambiar y crecer, y una vocación para ayudar a que sus pacientes lo hagan.

En la actualidad es un experto en adicciones reconocido internacionalmente; en 1976, el Dr. Ricardo González fundó en Cuba el primer servicio de atención a pacientes para el abuso de sustancias en el Hospital Psiquiátrico “Eduardo B. Ordaz” en La Habana, un programa que él dirigió hasta el año pasado. Este es ahora el centro nacional de referencia para otros 17 programas de este tipo, dos más en La Habana y uno en cada provincia cubana. Además, sirve como un modelo para los centros de tratamiento que atienden a viajeros internacionales (sin duda el más conocido de ellos, Diego Maradona, el astro del fútbol argentino): dos en la provincia de Holguín y uno en la provincia de Santiago, con otro que se está desarrollando en el Centro de Salud Internacional “Las Praderas” en La Habana.

Los 25 libros del Dr. González sobre psiquiatría, ética médica y adicciones dan fe de una prolífica carrera en la investigación y la práctica. Ahora él continúa el trabajo “desde su jubilación” como profesor consultante y psiquiatra en el servicio de adicción que fundó, y también preside la Comisión Nacional de Ética Médica de Cuba. En esta entrevista, el Dr. González comparte ideas a partir de sus años de experiencia tratando el abuso de sustancias, y nos habla sobre las repercusiones y el manejo de las adicciones en Cuba.

For over 40 years, he has done one of the most difficult jobs in medicine; 4000 of his patients are among those many might write off as “lost causes.” Yet he radiates optimism, his stories and experience reflecting a belief in the human potential to change and grow and a vocation to help his patients do so.

Now an internationally recognized expert on addictions, in 1976 Dr González founded Cuba’s first patient service for substance abuse at the Eduardo B. Ordaz Psychiatric Hospital in Havana, a program he directed until last year. It is now the national reference center for another 17 such programs, two more in Havana and one in every other Cuban province. In addition, it serves as a model for treatment centers catering to international patients (undoubtedly the most well known among them Diego Maradona, the Argentine soccer star): two in Holguin Province and one in Santiago Province, with another being developed at Las Praderas International Health Center in Havana.

Dr González’s 25 books on psychiatry, medical ethics and addictions attest to a prolific career in research and practice. Today, he continues to work “from retirement” as consulting professor and psychiatrist in the addiction service he founded, and also chairs Cuba’s National Medical Ethics Commission. In this interview, Dr González shares insights from his years of experience addressing substance abuse, as well as on repercussions and management of such conditions in Cuba.

In April 2013, a consortium of regional health ministries, nongovernmental organizations, aid agencies, clinical specialists and researchers from diverse sectors convened in San Salvador to discuss the epidemic of chronic kidney disease of unknown or non-traditional causes (CKDu) plaguing agricultural communities in Central America and beyond. The three-day meeting, where presentation of research on the clinical and epidemiological characteristics of CKDu roused significant debate, led the Pan American Health Organization to declare CKDu “a pressing and serious health problem [which] represents a burden for families, communities, health systems and society as a whole.”[1]

This High-level Meeting on Chronic Kidney Disease of Non-Traditional Causes in Central America (24–26 April) followed several international meetings at which Dr María Isabel Rodríguez, El Salvador’s Minister of Health, presented studies on the disease burden in her country, where end-stage renal disease is the leading cause of hospital deaths. She outlined results of original scientific research by Dr Carlos Orantes (first published in MEDICC Review), that described an “elevated prevalence of chronic kidney disease, chronic renal failure and risk factors” among the patients studied, noting that “the most common [form] was chronic kidney disease of unknown cause, associated with neither diabetes nor hypertension.”[2]

In this interview with MEDICC Review, Dr Rodríguez discussed the gravity of the problem in Salvadoran agricultural communities; the importance of CKDu research in other countries; and the urgent need for intersectoral action and active community participation to confront and control the epidemic.

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.

In the fall of 2008, MEDICC Review published a roundtable discussion with six of eight deans representing schools of health sciences with a strong social accountability mandate, who had just founded a new collaborative: the Training for Health Equity Network (THEnet). The topic was the changing paradigm of medical education. MEDICC Review returns to hear their perspectives on how their schools contribute to universal coverage, the theme of this issue.