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-oldplus 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.

A rights-based approach is also reflected in efforts to ensure a full range of health services and therapeutic options to Cuba’s transgender population. In Transgender Health in Cuba: Evolving Policy to Impact Practice, Senior Editor Conner Gorry documents the fits and starts of policy change championed by Cuban health professionals and gender minority people, confronting society’s homo- and transphobic biases over the decades to guarantee the Constitutional right to health care. In the process, their work is influencing not only health care but also culture, changing minds as well as transforming practice.

Calixto Machado takes on the complex dynamic among values, ethics and science in his Viewpoint Describing Life to Define Death: A Cuban Perspective. An international expert on brain death, he chaired the Cuban commission whose ten-year study led to formulation of the Cuban public health system’s guidelines for the definition and certification of death. Moreover, Dr Machado’s work has helped generate an evolving consensus in the global scientific community, which attempts to harmonize and integrate philosophical and neurological conceptualizations of life and death.

Contributing to a global consensus is also the aim of Ricardo González’ recommendation for a more comprehensive working definition of harmful alcohol use, considering the population health impact of non-social drinking recognized by the World Health Organization (WHO). His proposal would more precisely describe clinical criteria for harm to individuals (the International Classification of Diseases) and for the first time incorporate clear population health criteria for harmful use (Alcohol Harm: Beyond the Body to the Body Politic).

Cuba’s economic limitations, begging innovation and optimal use of scarce resources, provide context for research and practice published in this issue. Our reprint (Cuba’s Kidney Transplantation Program) carries an implicit warning of the increasing cost to the public health system of growing numbers of patients requiring renal replacement therapies in Cuba. This, in turn, points to the significance of the Isle of Youth Study (ISYS), total-population research using chronic kidney disease as a tracer for diverse forms of vascular damage that share common risk factors. Progress in establishing proportions of at-risk population and those already suffering vascular damage is reported in this article (Albuminuria as a Marker of Kidney and Cardio-cerebral Vascular Damage. Isle of Youth Study (ISYS), Cuba), among important baseline findings to inform strategic policy decisions on chronic disease prevention programs and effective distribution of human and material resources.

Clinical research on stem-cell therapies—using autologous adult stem cells since 2004 with some 1500 patients, primarily in angiology and orthopedics—has led to development of innovative, low-cost techniques that may enable their broader application in public hospitals throughout the country, transforming possibilities for hundreds more patients. (Generating Potential for Regenerative Medicine in Cuba, an interview with Porfirio Hernández of the National Regenerative Medicine Group).

Finally, this issue’s Special Article reports on a newly adopted methodology to set national priorities in health research (Priority Setting in Health Research in Cuba, 2010). While Cuba has been one of the relatively few developing countries to generate a national health research agenda, the process itself has been transformed to involve multiple stakeholders in a qualitative, interpretive approach that began in 2009. Through a wider participatory framework and involvement of health professionals from all levels of the health system, leaders of the exercise conclude that both national and local research priorities are now more clearly focused, enabling funds to be channeled to studies on the most pressing problems of health and the health system. Such a priority setting process, consulting a wide array of stakeholders with differing perspectives, has been identified as vital for countries to develop a more solid health research agenda, constructing the evidence base for changes in policy, organization and practice to improve population health.[1]

With the journal’s next issue, Managing Editor Kathleen Vickery transfers her responsibilities to Christina Mills MD FRCPC, a Canadian physician with ample experience in editorial work, public health and the field of chronic diseases. Kathleen’s expert editorial skills and professional dedication presided over the journal’s transformation into a peer-reviewed open-access publication, indexed in major services worldwide and read in over 50 countries. We will miss her quick mind, generous spirit, and grace under pressure. We have no doubt that Dr Mills will maintain and enhance the quality of MEDICC Review as we go forward.

1. Ranson MK, Bennett SC. Priority setting and health policy and systems research. Health Research Policy and Systems [Internet]. 2009 Dec 4 [cited 2010 Oct 22]; 7(27):[about 7 p.]. Available from: www.health-policy-systems.com/content/7/1/27.