Conner Gorry MA
The 1980s were a watershed for Cuban research in medicine and health: significant financing and material resources buttressed a strategy to improve population health through enhanced biopharmaceutical innovation and clinical best practices applied to Cuba’s universal public health system. Redirecting research priorities and providing substantial public funding to tackle the top population health problems was a radical idea at the time, especially for a developing country like Cuba. Doing so has become a hallmark of Cuba’s scientific achievements and approach ever since. Among the institutions exemplifying this strategy is the Pedro Kourí Tropical Medicine Institute (IPK). Founded in 1937 with a research mission dedicated to parasitology and transmission of known tropical diseases, it wasn’t until the late Dr Gustavo Kourí Flores was appointed director in 1979 that IPK’s core objectives and facilities were expanded to include a comprehensive teaching component, a state-of-the-art clinical hospital to treat tropical and other communicable diseases, and an international collaboration strategy to facilitate knowledge and technology transfer.
Today, IPK is Cuba’s national reference center for diagnosis, treatment, control and prevention of communicable diseases and is a regional leader in applied research into so-called neglected diseases—usually diseases of the poor. With departments of parasitology, bacteriology, virology, pharmacology and more, it’s a magnet for some of the country’s most accomplished scientists—most of them women—and a major contributor to Cuba’s portfolio of scientific products, research and publishing.
This interview with virologist Dr María Guadalupe Guzmán, director of IPK’s Reference Center for Research and Diagnosis, is the third in MEDICC Review’s series on outstanding Cuban women in science and medicine. Recognized as a leading expert in dengue research, Dr Guzmán is also director of the WHO/PAHO Collaborating Center for Dengue and its Control and was president of the Arbovirus Diagnosis Laboratory Network of the Americas (RELDA) from 2010 through 2018. Currently, she is president of the Cuban Society of Microbiology and Parasitology, directs IPK’s Scientific Council that sets the Institute’s research priorities, and is a distinguished professor and author. In 2016, she published Dengue (Editorial Ciencias Médicas, Havana), the most comprehensive collection of original Cuban research available on the topic.
Throughout the 1980s, Cuban researchers at the country’s biotech campus known as the Scientific Pole were making innovative discoveries and began developing unique therapies and vaccines unavailable elsewhere in the world. The pace and level of innovation meant prioritizing the establishment of a dedicated, internationally-certified institute for clinical trials. These and other accomplishments in science and related sectors, coupled with statistics revealing that 53% of all scientists in Cuba are women, prompted MEDICC Review to publish a series of interviews with outstanding Cuban women in science, technology and medicine.
In this, the second installment in the series, we spoke with Dr María Amparo Pascual, a biostatistician, researcher and professor, and the driving force behind the design and establishment of Cuba’s Clinical Trials Coordinating Center (CENCEC). From 1991 to 2014, Dr Pascual served as founding director of CENCEC. During that time the center implemented internationally-recognized good clinical practices (GCP), launched the National Clinical Trials Coordinating Network to support trials overseen by CENCEC, began conferring master´s and doctoral degrees in clinical trials; initiated a quality management system for all trials (receiving ISO 9001 certification in 2008) and created the Cuban Public Registry of Clinical Trials—a bilingual, WHO–accredited Primary Registry, the first in the Americas. In 2013, the BBC recognized Dr Pascual as one of the most influential female scientists in Latin America for her achievements, including becoming Cuba’s first biostatistician and her work at CENCEC.
After nearly 60 years of universal education and health, coupled with national policies supporting women’s rights and advancement, the results are in: according to recent data, more than half of Cuban scientists and almost 60% of all professionals in Cuba are women. Moreover, women’s representation in government is rising, including at the highest levels such as parliament, where they constitute 53.2% of members. Digging deeper, we find a story richer than national statistics or political representation. It’s the story of the collective achievements of female professionals on the island. For example, the clinical research team responsible for developing CIMAvax-EGF, Cuba’s novel biotech therapy for non-small cell lung cancer, was headed by a woman. Likewise, the lead scientist of the Cuban team that developed the world’s first effective meningitis B vaccine is a woman. And the cofounder of the country’s clinical trials coordinating center and registry is a woman, as is the founder of the National Center for Agricultural Animal Health. Yet, as in any country, there is more to be done to achieve true gender parity and release the full potential of women. To begin our series profiling outstanding Cuban women professionals, MEDICC Review spoke with sociologist Dr Marta Núñez, who has devoted decades to research on gender relations and the role of women in Cuba. She provides an overview and framework for contextualizing the advancement of Cuban women—including the challenges still to overcome.
On the 40th anniversary of the Alma Ata Declaration that affirmed health for all a right and primary health care the route to guarantee that right, WHO and PAHO have issued a call to action to convert universal health into reality for the nearly four billion people worldwide lacking full coverage of essential health services. There is some urgency to this movement: WHO estimates the health workforce shortage of nearly 8 million could reach almost 13 million by 2035. And the USA is not exempt: medical associations and special commissions set up to investigate the shortage of primary care physicians, especially “under-represented minority” doctors, have issued report after report on this growing health care emergency. The biggest question looming is: where will the health care providers come from, especially well-trained primary care doctors who want to work for those who need them most?
Part of the answer may be found in Cuba and its Latin American School of Medicine (ELAM), which has graduated some 28,500 MDs from 103 countries since its first class of 2005—including nearly 200 from the USA. Graduates, most from low-income families, are not only admitted for their intellect and academic records, but also for their social commitment.
MEDICC Review looked to a group of these US graduates to better understand their decision to study medicine in Cuba and how they faced the resulting challenges, as well as the relevance of their Cuban education to their current practice.
In this Retrospective, MEDICC Review reprints excerpts from a blog by Senior Editor Conner Gorry, who, during February and March 2010, was embedded in the disaster-response medical team sent from Cuba after the January 12 earthquake. The team reinforced nearly 500 Cuban health personnel already on the ground long term in 120 communities. Some 700 of the 1300 new arrivals were students or graduates of Cuba’s Latin American School of Medicine from 27 countries. Haitian graduates now number 1044. The international contingent (named after Henry Reeve, a Brooklyn-born general in Cuba’s own independence struggle) became the largest medical relief effort assembled after the quake.
Cuba’s nascent biotechnology sector began making scientific breakthroughs in the 1980s, including the isolation of human leukocyte interferon alpha (1981) and the development of the world’s first safe, effective meningitis BC vaccine (1989). With positive results in hand and a growing R&D pipeline, the island nation established a national regulatory authority (NRA) to implement and oversee best practices for all pharmaceuticals and medical devices, domestically produced and imported, used in the country’s universal health system. Founded in 1989, Cuba’s Center for State Control of Medicines and Medical Devices (CECMED) is the entity charged with regulating all phases of scientific innovation for health, from clinical trial design to postmarketing surveillance.
Dr Rafael Pérez Cristiá, Distinguished Member of the Cuban Academy of Sciences, has been Director General of CECMED since 2000, overseeing regulation and control of unique and innovative biotechnology products and the concomitant evolution of the nation’s regulatory authority. Under his guidance, CECMED has regulated unique therapies, vaccines, and pharmaceutical products—some unavailable anywhere else in the world—aimed at improving population health both at home and abroad. Recognized internationally as one of the top 20 countries with a safe and reliable biotechnology industry and regulatory authority, Cuba is having a measurable impact on public health. In this exclusive interview, Dr Pérez Cristiá, explains how a small, resource-scarce country has rocketed into the global biotech elite—and how it intends to stay there.
Challenges abound, however, to guarantee the healthy development of autistic Cubans and the wellbeing of their families and caretakers, while improving awareness and understanding by society at large about this complicated disorder. The most immediate hurdle facing island health authorities is: precisely what is the prevalence of ASD in the country? To date, no national survey has been conducted establishing a baseline for how many people are affected. Without these data, prioritizing programs for this vulnerable population is more difficult, as is resource allocation, defining training needs, and scientific research design. Although all Cubans with disabilities regardless of origin or type are protected by law,[1] a total-population study is needed not only to determine the extent of the health problem, but also the implications for Cuban families, the health and education systems, and the national economy. According to WHO, integrating autistic children and adults into society is a priority requiring “actions for making physical, social, and attitudinal environments more accessible, inclusive and supportive.”[2] An incomplete evidence base slows progress of these actions, hindering Cuba’s goals of social insertion and inclusivity.
Cuando en 1981 un grupo de científi cos cubanos, entrenados por colegas finlandeses, aislaron exitosamente grandes cantidades de interferón humano leucocitario, nacía la biotecnología cubana.
En la década siguiente y como respuesta a una inversión de mil millones de dólares del gobierno cubano, en La Habana y sus alrededores se fundaron 52 instituciones de investigación científica con el propósito de desarrollar vacunas, terapias y otras aplicaciones médicas que satisficieran las necesidades del Sistema
Nacional de Salud.
La estrategia —basada en el enfoque de “ciclo cerrado”[1] en el que investigación, desarrollo, producción, ensayos clínicos, comercialización y vigilancia post-comercialización son coordinados por un solo instituto de investigación en cooperación con otros— tiene como primera prioridad el suministro de soluciones
efectivas para los problemas de salud más acuciantes en Cuba.
Su segunda prioridad fue, y sigue siendo, generar ingresos a partir de las exportaciones, ingresos que son en gran medida reinvertidos en investigación y desarrollo y en infraestructura, de modo que, con el tiempo, la industria se independice del fi nanciamiento gubernamental.
El mundo se hallaba absorto en el aterrizaje del presidente Barack Obama en La Habana en marzo del 2016, el primer presidente estadounidense en visitar Cuba en 88 años. En toda la isla, los cubanos anticipaban la llegada de Obama con incrédula esperanza; era difícil imaginar que el acercamiento había llegado tan lejos después de décadas de distanciamiento y hostilidad. Las calles de la capital eran un hervidero, con los cubanos afanados en esfuerzos de embellecimiento urbano para recibir a la Primera Familia de los Estados Unidos con estilo. Sin embargo, La Habana también bullía con algo más, una amenaza que trasciende la política, las fronteras nacionales y las diferencias de opinión: los mosquitos que transmiten zika, dengue y chikungunya. Estas infecciones por arbovirus se propagan por dos mosquitos Aedes (aegpyti y albopictus), criaturas muy adaptables que pican durante el día y prosperan en climas urbanos calientes.
In 2015, a record-breaking 3.5 million visitors—1 million from Canada alone—traveled to Cuba to explore its history, culture, natural splendor, and visit family. That same year, US President Barack Obama relaxed travel restrictions, giving general authorization for a dozen categories of legal travel by US citizens and residents. As a result, US visitors to the island ballooned by 80% between January 2015 and June 2016. And the numbers keep growing: the latest data show that foreign arrivals reached 4 million in 2016.[1] The surge in visitors highlights the potential negative impact of tourism on a developing country’s infrastructure, environment, cultural patrimony and local economy—all considered important social determinants of health.
Nurse Sarait Guarat has Felipe’s clinical history out of the file cabinet and on Dr Martha Diaz’s desk before he’s even through the door. Not that Dr Díaz needs it: Having served 26 years at Consultorio (Family Doctor-and-Nurse Office) #17 on a leafy street in Havana’s Vedado neighborhood, she knows each of her patients by name and their health status essentially by heart. After greeting 91-year old Felipe with the customary kiss on the cheek, Dr Díaz gets down to business, asking after his family, checking up on his diabetes and inquiring about the reason for his visit.
“He’s had an upset stomach and some diarrhea, doctora,” his wife says from across the room. “That’s not good. Let’s find out what’s going on,” responds Dr Díaz, glancing at Felipe with a smile while donning her stethoscope to listen to his heart. After Felipe is weighed by Sarait, a nurse with 25 years’ experience in Cuban primary care, Dr Díaz takes his blood pressure and commends him for his healthy 110/70.
Soon after the Molecular Immunology Center (CIM) was established in 1994 (a founding institution of Havana’s biotechnology and pharmaceutical campus known as the scientific pole), Dr Crombet completed her master’s thesis there. She joined CIM’s team in 1998 and in 2004 was designated Director of Clinical Research. She has participated in the research, development and clinical trials of some of Cuba’s most innovative therapies and vaccines, including CIMAvax-EGF for non-small cell lung cancer patients. In 2015, this therapy completed Phase IV clinical trials in Cuba and is now used in primary health care services throughout the country’s national health system. CIM and Roswell Park Cancer Institute (Buffalo, New York) received US Department of Treasury approval in 2015 to test CIMAvax-EGF and other CIM products in the United States, opening the way for the Food and Drug Administration (FDA) to consider joint ground-breaking Phase I and II clinical trials in the USA. Recent regulatory changes introduced by President Barack Obama may make applying for such licenses a thing of the past—at least that is what researchers hope.
In any case, the work of Dr Crombet and the teams at CIM is making headway in cancer immunotherapy, within the broader goals of the institution’s mandate…the subject of our interview.
In 1981, Cuba’s biotechnology sector was born when Cuban scientists, trained by Finnish colleagues, successfully isolated large quantities of human leukocyte interferon alpha. Within a decade and following a $1-billion dollar investment by the Cuban government, 52 scientific research institutions were established in and around Havana to develop vaccines, therapies and other medical applications to meet demands of the national health system.
The world sat rapt as President Barack Obama touched down in Havana in March 2016, the first US President to visit Cuba in 88 years. Across the island, Cubans anticipated Obama’s arrival with hope-tinged disbelief; it was hard to fathom that rapprochement had come this far after decades of estrangement and hostility. The capital’s streets were abuzz, with Cubans throwing themselves into urban beautification efforts to receive the US First Family in style. Yet, Havana also buzzed with something else, a threat that transcends politics, national borders and differences of opinion: the mosquitoes that transmit Zika, dengue and chikungunya. These arboviral infections are spread by two Aedes mosquitoes (aegpyti and albopictus)—highly adaptable creatures that bite during the day and thrive in hot urban climates.
Llámeles intrépidos pioneros o simplemente tenaces: más de 200 estudiantes de Estados Unidos, principalmente de minorías marginadas y de familias de bajos ingresos, decidieron que se convertirían en los médicos que necesitan sus comunidades, y que sería la Escuela Latinoamericana de Medicina de Cuba (ELAM) la que los prepararía para el trabajo.
Al hacerlo, aceptaron una multitud de desafíos, entre ellos el de estudiar en un país elogiado por sus indicadores de salud poblacional, pero vilipendiado durante décadas por su gobierno. Bajo el presidente George W. Bush, la inscripción en la escuela requería incluso la intervención del entonces Secretario de Estado Colin Powell y del Caucus Negro del Congreso, cuyos miembros representan distritos con algunos de los peores indicadores de salud de los Estados Unidos. Una vez aceptados por la ELAM, que tiene sus propios requisitos académicos altos, no estaba claro si podrían afrontar la vida en Cuba, un país pobre con recursos limitados. Y luego viene el reto de aprobar el Examen de Licencia Médica de Estados Unidos (US Medical Licensing Examination, USMLE), que se exige a todos los estudiantes de medicina de Estados Unidos para obtener plazas en los programas de residencia.
Además de estos obstáculos había otra gran interrogante: ¿trabajarían realmente en comunidades remotas, en distritos urbanos de bajos recursos y pobres o simplemente aprovecharían la educación médica gratuita y abandonarían los objetivos sociales inculcados por su alma mater?
El concepto de la ELAM es simple, pero audaz: brindarle educación médica gratuita a estudiantes brillantes dispuestos a convertirse en médicos, pero que carecen de los medios económicos para ello, los motivará al regresar a servir en comunidades como las propias. Ellos pasan seis años estudiando ciencias básicas, medicina clínica y salud pública. A partir de la primera graduación en el 2005, la ELAM ha capacitado cerca de 25 000 médicos —la mayoría mujeres y muchos de ellos indígenas— de 84 países, incluido Estados Unidos.
Una década después de que el primer graduado de Estados Unidos recibió su diploma de la ELAM, otros 113 se han graduado. Mientras que la mayoría de los graduados (especialmente los recientes) están aún terminando sus exámenes de USMLE, el 40% de ellos ya está cursando la residencia o la ha completado. De estos, el 90% ha elegido ejercer en tres especialidades principales de atención primaria —medicina familiar (61%), medicina interna (23%) y pediatría (6%). De los graduados estadounidenses que ya ejercen, el 65% trabaja en áreas deficitarias en profesionales de la salud (Health Professional Shortage Areas, HPSA) o áreas médicamente desatendidas (Medically Underserved Areas, MUA). El éxito de estos médicos también ayuda a eliminar el estigma del programa de Cuba; en Estados Unidos, los médicos graduados en el extranjero son a menudo percibidos como menos competentes, ya que se asume que estudian en el extranjero porque no lograron ser aceptados en otro lugar. Pero frecuentemente, como en el caso de los médicos formados en la ELAM, la educación médica de Estados Unidos supone una barrera económica, no intelectual, para su formación.
La Universidad de Ciencias Médicas de La Habana es una de las 14 escuelas de medicina en Cuba. En sus ceremonias de graduación de julio, se entregaron diplomas a más de 1 200 médicos de Cuba, América Central y del Sur, el Caribe, África y Asia —que incluye a los graduados de la ELAM, entre ellos 21 de Estados Unidos.
MEDICC Review entrevistó a varios graduados estadouni-denses de la ELAM mientras se preparaban para regresar a sus hogares —Wyoming, Luisiana, Pennsylvania, Texas, Florida y otros lugares. Hablaron con franqueza sobre las ventajas y los desafíos de estudiar medicina en Cuba, el proceso de concesión de licencias para ejercer en los Estados Unidos, y sus planes para el futuro.
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.
