To the Editors:
As of January 2013, Cuba lost access to the bulk of the international health sciences literature, which it had previously been able to access online at a reasonable price through the WHO-led program, HINARI (Health InterNetwork Access to Research Initiative) (MEDICC Review Editorial and Viewpoint, Vol. 15. No. 2, April 2013). Cuba’s exclusion and that of 13 other countries was based on the fact that they are no longer eligible for the program because of their GNI level and positive position in the Human Development Index (HDI).

In my view, this automatic exclusion is unjust and ignores the particulars of the situation Cuba faces, to wit:

• Although there has been an increase in Cuba’s GNI per capita, the country is still subject to the US economic blockade that the UN General Assembly itself has repeatedly condemned by absolute majority for over a decade. This situation means that Cuba does not fully benefit from increased income, and it produces additional frictions and associated costs that limit the country’s capacity to reach equitable trade agreements. The fact that many publishers offering access to scientific journals are located in the United States makes Cuba’s situation particularly disadvantageous, given the blockade’s banking restrictions.
• Cuba has one of the world’s most coherent and sustained programs for global health cooperation and training. Through this exceptional program, recognized by WHO and the international community, Cuba has for decades devoted a significant portion of its national income to helping countries in worse situations, consistent with one of HINARI’s founding principles: integration under WHO leadership of efforts to support countries’ socioeconomic development by improving their population health.
• Cuba worked with WHO to develop HINARI, paying regularly for its services, and making prudent and responsible use of its resources since 2002—taking on the cost of connectivity, higher because of the external conditions already mentioned. This access to scientific information served a scientific community and health system that, in addition to its international contributions, continued to provide free health care to its own population, leading to steadily improved health indicators that partially explain Cuba’s position in the HDI. HINARI reached the whole Cuban health system through INFOMED, despite limited connectivity and scarce resources.[1]

One of the founding principles of HINARI is precisely the commitment to equitable pricing. According to Barbara Aronson, program founder, “The primary information of biomedicine is essential to achieving population health in the developing world. If it is priced, the cost should be proportionate to the ability of the user to pay.”[2]

Cuba’s case is particularly difficult, because, besides having limited resources to pay for access to scientific literature, it is also at a disadvantage when it comes to equitable access to the scientific publishing market. As long as the US blockade persists, Cuba will have unequal access to the scientific literature needed for health development.

The cost of obtaining such international literature without support from a program like HINARI is not proportionate to the ability to pay—either of the country, its citizens or its institutions. And that constitutes an inequity.

It is within the spirit and commitment of organizations like the WHO, and a program like HINARI, to find a way to keep Cuba, its professionals and ultimately its people—actors and beneficiaries of health—from being excluded from an effort of such seriousness and palpable results.

1. Séror AC. A Case Analysis of INFOMED: The Cuban National Health Care Telecommunications Network and Portal. J Med Internet Res [Internet]. 2006 Jan [cited 2009 Jul 31];8(1). Available from: http://www.jmir.org/2006/1/e1/HTML
2. Aronson B. WHO’s Health InterNetwork Access to Research Initiative (HINARI). Health Info Libr J. 2002 Sep;19(3):164–5.

Pedro Urra MS (pedro.urra@infomed.sld.cu)
Full professor, University of Havana, Cuba
Founding director, INFOMED & former director, National Medical Sciences Information Center

To the Editors:
The last issue of MEDICC Review referred to a recent event with a highly negative impact on public health in Cuba: the decision by WHO and international medical journal editors to suspend Cuba’s access to HINARI.

The reason given for this decision is that Cuba’s Human Development Index (HDI) is high enough to make it ineligible for this subsidized service. Normally, a country’s HDI is directly related to its economic development, but that is not the case for Cuba. Cuba’s health indicators that positively influence its HDI have been achieved as a result of government political will, prioritizing a free, universally accessible health system. Cuba has suffered an economic blockade for more than 50 years and has focused its very limited economic resources on ensuring an inalienable right, the right to health. To that end, Cuba has trained health professionals with the human and ethical values to put people first.

Suspension of access to HINARI reflects a cruel paradox. On the one hand, Cuba’s improvements in health and human development must be seen as positive. On the other, these very improvements now deprive us of access to the scientific knowledge so vital to using our limited resources optimally. And not only for the Cuban population’s wellbeing, but also that of dozens of developing countries where Cuban health professionals provide health care to millions of people, to improve their HDI.

In my own field of human genetics, the rate of knowledge production is dizzying, as illustrated in headlines daily in the mainstream media as well as specialty journals. Without HINARI, how can Cuban geneticists—deprived by the blockade and economic constraints of access to modern diagnostic and research technology for our labs from the very beginning of our program—keep current with advances in our field, think about new lines of investigation, compare our research methods and results with studies elsewhere, and contribute to training health professionals for developing countries whose citizens remain unaware of even the most elementary benefits of the knowledge produced in medical genetics every day?

I invite WHO and the medical journal editors involved in HINARI to reconsider their decision. Doing so would also give them the opportunity to continue collaborating with Cuban public health programs and advances. Not doing so would erect one more obstacle in the path of our peoples’ right to health and wellbeing.

Beatriz Marcheco Teruel MD PhD (beatriz@infomed.sld,cu)
Director, National Medical Genetics Center, Havana, Cuba
President, Cuban Society of Human Genetics

To the Editors:
The issue of access to timely and useful scientific information, raised in your Editorial and Dr Mikhail Benet’s Viewpoint in MEDICC Review’s April 2013 issue, is of great importance for Cuban health professionals. Our expulsion from HINARI means that a huge proportion of international medical journals have now become inaccessible to us. All of us depended on the wealth of information available through HINARI. My own investigations of medical history, particularly of epidemics in modernity, were facilitated by HINARI. All that is lost to me.

But I am not the only one affected. I worry particularly about young professionals, those still in training, residents and graduate students, who need to consult current information and complementary bibliography. It is also a terrible limitation for clinicians who want to keep up to date and are continually searching for new insights in their areas of practice or on general scientific topics.

My concern does not only stem from my interest as an investigator. As the head of research at the National Medical Sciences Information Center [CNICM, the Spanish acronym], I see the need for researchers to be able to manage information to develop theoretical frameworks for their studies; they must familiarize themselves with the state of knowledge on the topic they intend to pursue. As a professional committed to our work at CNICM, I uphold free access to information, so that any interested person can read and benefit from what is published. In health, the benefit is not just personal, but extends to the population served by these professionals. And as a professor, I see the impact and limitations this recent decision places on learning.

Hence I call on those responsible to reflect on their decision’s negative consequences, particularly for Cuban health professionals and for the public at large.

Enrique Beldarraín MD PhD (ebch@infomed.sld.cu)
Full professor, senior researcher and head of research
National Medical Sciences Information Center, Havana Cuba

To the Editors:
I read with interest Benet’s article, Cuban Publishing on Primary Health Care: An Inexcusable Absence in your April issue and would like to comment. I agree with the author that primary care is the basic pillar of the Cuban health system and that its experiences can provide useful lessons to other developing countries. We need scientific publications to be able to share those experiences.

In this context, I want to underline the importance of the author’s comments on WHO’s decision to declare Cuba ineligible for continued access to HINARI. This service, which Cuban physicians have used extensively, is a WHO project to help developing countries with a low HDI. Cuba’s higher HDI last year led WHO to exclude us from the project, jeopardizing the work of health professionals here. The decision is unfair and unjust; Cuba has given and continues to give practical health assistance to many countries around the world. The research results our health professionals access through HINARI are used to improve our own people’s health as well.

The HINARI decision is particularly ill-advised when the open-access movement in scientific publishing is gaining more support by the day, from both institutions and individuals in the scientific
community. Witness the Berlin Declaration on Open Access to Knowledge in the Sciences and Humanities, affirming the open access paradigm and its great advantages for knowledge dissemination:

Our mission of disseminating knowledge is only half complete if the information is not made widely and readily available to society. New possibilities of knowledge dissemination not only through the classical form but also and increasingly through the open access paradigm via the Internet have to be supported. We define open access as a comprehensive source of human knowledge and cultural heritage that has been approved by the scientific community…[1]

The success of the open-access movement resides not only in its advantages in availability and access to electronic publishing, but also in the support it gives to a scientific community that endorses that model for research, dissemination and impact.[1] When the scientist has a social commitment—as is the case in Cuba—his or her need to keep up to date scientifically and technically is not just for personal benefit, to earn a credential or improve a procedure or course, but also to achieve better patient care, which benefits all of society.

The HINARI decision is incomprehensible, and I urge its reconsideration. Further, I invite the HINARI journals to join the open- access movement. Congratulations to Dr Benet for an interesting article.

1. Berlin Declaration [homepage on the Internet]. Berlin Declaration on Open Access to Knowledge in the Sciences and Humanities. [Cited 2013 Jun 24]. Available from: http://oa/mpg.de/openaccess-berlin/berlindeclaration.html

Ricardo Hodelín Tablada MD MS PhD (rht@medired.scu.sld.cu)
Neurosurgeon, full professor and senior researcher
Saturnino Lora Clinical-Surgical Teaching Hospital
Santiago de Cuba

To the Editors:
With the 1976 creation of Cuba’s Ministry of Higher Education came the recognition of research training as a core function of the university, ratified by the policies of the Ministry of Science, Technology and Environment. The promotion of research has enabled Cuba to achieve science, technology and health indicators among the highest in the Americas, thanks to continued improvements in undergraduate and graduate professional education.[1]

Nevertheless, the Cuban health system’s scientific productivity has still not lived up to its professionals’ potential, and doctoral-level training in the health sector is not as efficient as it could be. Medical education is working to develop students’ and practitioners’ scientific thinking, especially in patient care, including clinical and the epidemiologic methods.[2] The aim is to prepare students to systematically apply scientific reasoning in their future professional practice.

The biomedical research unit of the Medical University of Villa Clara conducts a number of projects, among them an anthropometric assessment of pregnant women in relation to pregnancy outcome, which brings together students and health professionals at different stages of training. The topic is closely linked to research on the global obesity epidemic, and pertinent new findings are constantly published on the Internet and even promoted by WHO. So it seems paradoxical that WHO recently decided to suspend Cuba’s access to scientific publications through HINARI, denying Cuban professionals the means to stay current in their fields.

For educators in the medical sciences, particularly those of us involved in improving research at the postgraduate level, this decision is unjust and unacceptable.

1. Duriez González M. El papel de la educación superior en la construcción del conocimiento [Internet]. Venezuela: UNESCO; 2008 [cited 2009 Jul 18]. 44 p. Available from: http://www.robertoreyna.com/puertaes/cres%20pdf/contribuciones%20a%20los%20documentos%20basicos/tema%20vii/ maribel%20duriez%20gonzalez%201.pdf. Spanish. 44 p.
2. Sarasa Muñoz Nélida L. ¿Por qué didácticas o metodologías particulares en el proceso docente educativo de Medicina? EDUMECENTRO [Internet]. 2013 Jan–Abr [cited 2013 Jun];5(1):11–7. Available from: http://www.edumecentro.sld.cu/pag/Vol5%281%29/cartednelida.html. Spanish.

Nélida L. Sarasa Muñoz MD MS PhD (nelidasm@ucm.vcl.sld.cu)
Medical University of Villa Clara, Santa Clara, Cuba