Helena J. Chapman MD MPH PhD, Luisa A. Armas-Pérez MD MS, Michael Lauzardo MDMS,
Edilberto R. González-Ochoa MD PhD

Global efforts to eliminate tuberculosis by 2050 continue to challenge health systems. In countries with low reported tuberculosis incidence, such as the USA (3.1/100,000 population) and Cuba (6.9/100,000), differences in classification by income level and health systems’ overall organizational structure are evident. However, the two countries’ low tuberculosis incidence, geographic proximity, robust research capacity and shared health priority for tuberculosis elimination provide fertile territory to strengthen collaboration for tuberculosis control in clinical, laboratory and community settings. Two tuberculosis symposia in Cuba—one at the Cuba Salud Convention in 2015 and the other at the International Forum on Hygiene and Epidemiology in 2016—were instrumental in stimulating dialogue on continued efforts towards eliminating tuberculosis by 2050. In this article, we describe tuberculosis burden in the USA and Cuba, critically analyze strengths and challenges experienced in areas of low tuberculosis incidence and provide recommendations for future institutional collaboration to support tuberculosis elimination and improved population health.

KEYWORDS Tuberculosis/epidemiology, Mycobacterium tuberculosis, prevention, communicable disease control, disease eradication, disease elimination, international cooperation, Cuba, USA

Erratum
Page 60, Table 1, rows 9 and 10: row labels “New cases (%)” and “Previously treated cases (%)” should be indented, to make clear that they are subsets of MDR-TB cases.

Protein–energy malnutrition affects one in nine people worldwide and is most prevalent among children aged less than five years in low-income countries. Early childhood malnutrition can have damaging neurodevelopmental effects, with significant increases in cognitive, neurological and mental health problems over the lifespan, outcomes which can also extend to the next generation. This article describes a research collaboration involving scientists from five centers in Barbados, China, Cuba and the USA. It builds on longer-term joint work between the Barbados Nutrition Study (which, over a 45-year span, has extensively documented nutritional, health, behavioral, social and economic outcomes of individuals who experienced protein–energy malnutrition in the first year of life and healthy controls from the same classrooms and neighborhoods) and the Cuban Neuroscience Center (which has developed low-cost brain imaging methods that can be readily used in low income settings to identify biomarkers for early detection and treatment of adverse consequences of childhood malnutrition).

This collaboration, which involved Barbadian, Cuban and US scientists began in the 1970s, when quantitative EEG techniques were applied to EEG data collected in 1977–78, at which time study participants were aged 5–11 years. These EEG records were never fully analyzed but were stored in New York and made available to this project in 2016. These data have now been processed and analyzed, comparing EEG findings in previously malnourished and control children, and have led to the identification of early biomarkers of long-term effects of early childhood protein–energy malnutrition. The next stage of the project will involve extending earlier work by collecting EEG recordings in the same individuals at ages 45–51 years, 40 years later, and comparing findings to earlier data and to these individuals’ behavioral and cognitive outcomes. Quantitative EEG biomarkers of the effects of protein–energy malnutrition may help identify children at greatest risk for early malnutrition’s adverse neurodevelopmental effects and inform development of targeted interventions to mitigate the long-term adverse effects of protein–energy malnutrition in developing countries.

KEYWORDS Protein–energy malnutrition, electroencephalography, EEG, biomarkers, neurosciences, Barbados, Cuba, USA

In 1961, the USA severed diplomatic relations with Cuba, and in 1962 an embargo was imposed on trade and financial relations with that country. It was not until five decades later that the USA and Cuba would reestablish relations. This opened the way for the New York State Trade Mission to Cuba in April 2015, during which Cuba’s Molecular Immunology Center and Buffalo, New York’s Roswell Park Cancer Institute signed a formal agreement that would set in motion biotechnology research collaboration to address one of the most important causes of death in both countries. Significant research from Cuba led to this groundbreaking collaboration. The purpose of this paper is to discuss the development of this cooperation, from the Molecular Immunology Center’s initial investigations, through the opening of a phase I clinical trial at Roswell Park Cancer Institute with therapies developed at the Center. This cooperation was responsible for the first clinical trial for CIMAvax-EGF involving advanced-stage non-small cell lung cancer patients in the USA. A license was also approved by the US Department of the Treasury’s Office of Foreign Assets Control authorizing a commercial partnership for development of biotechnology products, combining the cancer research efforts of both institutions. This unusual collaboration between Cuba and the USA—the US economic embargo and travel restrictions not withstanding—opens good prospects for expanded medical research between the two countries. While political and logistical challenges remain, the shared mission and dedication of these Cuban and US scientists points the way towards relationships that can lead to development, testing, approval and use of promising new therapies for cancer patients.

KEYWORDS Biotechnology, clinical trials, cancer vaccines, cancer immunotherapy, non-small cell lung cancer, NSCLC, Cuba, USA

Gastroenterology, hepatology and liver transplant exchanges between the USA and Cuba have mainly consisted of scientific events and short visits. This has facilitated Cuba’s inclusion in recognized scientific organizations, familiarity with Cuba’s biotech products for treatment of liver disease, and access by Cuban professionals to the highest level of scientific information for clinical practice. It has also given health professionals in the US a more accurate picture of Cuba’s health sector. The results of the Global Alcoholic Liver Disease Survey, which included Cuba and was designed and coordinated in the USA, opened doors to joint research and scientific publications. Until now, there have been no protocols for ongoing cooperation to enable bilateral clinical trials or continuing professional development in diagnostic, therapeutic and surgical techniques for hepatology and liver transplantation. There are many mutually beneficial research prospects in these areas. What has been accomplished to date, described in this article, is encouraging and sets the stage for future collaboration.

KEYWORDS Hepatology, liver transplant, health, medicine, science, Cuba, USA

Joan O’Connell MHSc PhD, Ana María Gálvez-González PhD, Jean Scandlyn PhD, María Rosa Sala-Adam MS DDS, Xiomara Martín-Linares MS

In 2011, the US Department of the Treasury changed its regulations to allow US students to participate in short-term education programs in Cuba. Beginning in 2012, and each year thereafter, Cuba’s National School of Public Health and the Colorado School of Public Health have jointly taught a class on the Cuban public health system. The program goals are to provide US students with an opportunity to learn about the Cuban national health system’s focus on 1) prevention and primary health care services; 2) financial and geographic access to services and health equity; 3) continuum of care across the home, family doctor-and-nurse offices, polyclinics and hospitals; 4) data collection at all levels to understand health risks, including outbreaks, and to guide resource allocation; 5) assessing patients’ health and risks using a comprehensive definition of health; 6) multisectoral collaborations between the Ministry of Public Health and other Cuban agencies and organizations to address population health risks; 7) disaster preparedness, response and recovery; and 8) provision of international health assistance. The class incorporates information about health systems in Latin American and other Caribbean countries to provide context for understanding the Cuban health system.

The course includes: 1) seminars, online readings and discussions before travel to Cuba; 2) seminars at Cuba’s National School of Public Health, visits to Cuban national health institutions at all levels, from community-based family doctor-and-nurse offices and multispecialty clinics (polyclinics) to internationally recognized national health institutions, and guided visits and activities about Cuban culture and history during their 12 days in Cuba; and 3) followup course work upon return to the USA in which students integrate what they learned into their final class reports and presentations. During time spent planning, implementing and revising the program, both institutions have learned from each other about global health teaching methodologies and have laid a foundation for future teaching and research collaborations. To date, 49 individuals have participated in the program.

KEYWORDS Medical education, public health system, collaboration, Cuba, USA

After December 17, 2014, when the US and Cuban governments announced their intent to restore relations, the two countries participated in various exchange activities in an effort to encourage cooperation in public health, health research and biomedical sciences. The conference entitled Exploring Opportunities for Arbovirus Research Collaboration, hosted at Havana’s Hotel Nacional, was part of these efforts and was the first major US–Cuban scientific conference in over 50 years. Its purpose was to share information about current arbovirus research and recent findings, and to explore opportunities for future joint research. The nearly 100 participants included leading arbovirus and vector transmission experts from ten US academic institutions, NIH, CDC, FDA and the US Department of Defense. Cuban participants included researchers, clinicians and students from Cuba’s Ministry of Public Health, Pedro Kourí Tropical Medicine Institute, Center for Genetic Engineering and Biotechnology, Center for State Control of Medicines and Medical Devices and other health research and regulatory organizations. Topics highlighted at the three-day meeting included surveillance, research and epidemiology; pathogenesis, immunology and virology; treatment and diagnosis; vector biology and control; vaccine development and clinical trials; and regulatory matters. Concurrent breakout discussions focused on novel vector control, nonvector transmission, community engagement, Zika in pregnancy, and workforce development. Following the conference, the Pedro Kourí Tropical Medicine Institute and the US National Institute of Allergic and Infectious Diseases have continued to explore ways to encourage and support scientists in Cuba and the USA who wish to pursue arbovirus research cooperation to advance scientific discovery to improve disease prevention and control.

KEYWORDS Arboviruses, flavivirus, Zika virus, chikungunya virus, dengue virus, research, disease vectors, Cuba, USA

Scientific research cooperation between Cuba and the USA has a long history that dates back to the 19th century. For the past 200 years, the two countries’ relationship has been subject to complex economic, political and social forces. In the second half of the 20th century, the Cuban revolution and the subsequent escalation of the US government embargo impacted every aspect of Cuban life. While science was no exception, scientific interactions never ceased. Over the past decade, scientific cooperation—led and facilitated by scientific organizations such as the Cuban Academy of Sciences, the American Association for the Advancement of Science and others—has steadily increased to address ever more critical issues facing both countries. Science and global health diplomacy were key to reestablishing a trusting and productive relationship of mutual and global benefit after the USA and Cuba restored diplomatic relations in 2015. However, recent changes in Cuba policy by the new US administration are jeopardizing these opportunities for increased scientific cooperation, which are in the best interests of people in both countries.

KEYWORDS International cooperation, academies and institutes, Cuba, USA

INTRODUCTION In 2012, North Carolina ranked in the top ten states in refugee resettlement, with central Guilford County one of the most diverse in the southeast.

OBJECTIVE Examine the local resettlement environmental, nutrition and health barriers and needs of refugees in Guilford County, as perceived by individuals providing services to them.

METHODS Participants (n = 40) included: medical and social service providers, educators, faith-based volunteers, resettlement agency caseworkers and liaisons to a variety of refugee communities. Guided semistructured interviews were audio-recorded and transcribed verbatim. Themes were identified using deductive content analysis and categorized by frequency of reporting by participants.

RESULTS Perceptions were consistent across participants regarding a diverse local refugee population. Resettlement housing was observed to be in poor condition, located in areas of poverty with transportation barriers. However, refugees rarely relocated, due to strong community relationships and support. Perceived dietary risks included: difficulties budgeting and maintaining food assistance, hoarding food, high consumption of sodas and sweets, misperceptions regarding US products (e.g., perceived need for infant formula), and limited health knowledge. Respondents observed that most refugees preferred “fresh” foods, and had strong agricultural skills but lacked green space. Major barriers to health care reported were: poverty, short duration of initial Medicaid coverage, and language (both lack of interpretation services and translated materials). Providers consistently observed type 2 diabetes, weight gain and dental problems across refugee groups.

CONCLUSIONS Direct service providers’ experiences and observations working with a diverse resettlement population provide unique insight into consistent barriers to achieving good health that confront refugees. While refugees face many barriers, groups often have impressive strengths, such as agricultural skills, on which to focus.

KEYWORDS Refugees, emigration, immigration, minority health, health care disparities, diet, environment, USA

INTRODUCTION Asylum seekers face a wide array of challenges, including the need for a fair and just adjudication process. In the state of Georgia, the Atlanta Asylum Network addresses the needs of such individuals by providing them physical, psychological and gynecological assessments, the results of which are presented to the courts in the asylum appeal process.

OBJECTIVE As a component of the Network’s program evaluation, assess outcomes among asylum seekers using its services, as well as relation of outcomes to type of service provided, the individual’s geographic origin and English language proficiency.

METHODS A retrospective examination was conducted of program data gathered by the Network between 2003 and 2012. Subjects included asylum seekers who received assessments by the Network during this period. The primary variable of interest was the final case outcome, defined as determination of asylum status: granted, withholding of removal, administrative closure and prosecutorial discretion, denied or voluntary departure. Outcomes were subsequently collapsed into a single positive or negative outcome variable. Positive outcomes included asylum granted, removal withheld, administrative closure and prosecutorial discretion. Negative outcomes included asylum denied and voluntary departure. We conducted bivariate and multivariate analyses, relating final case outcomes to Network services, geographic origin and English language proficiency, among the key variables.

RESULTS A total of 69 of 120 asylum seekers in the study had a known final case outcome, and of those, 63.8% (44) had a positive outcome; or 37% of the total number of asylum seekers (n = 120). Among the 20 who received 2 of the 3 types of assessment (physical, psychological, gynecological), 16 (80%) received a positive case outcome. Most persons with a known final outcome came from Africa (41), where 78% (32) of cases resulted positive. Asylum seekers not proficient in English were 2.4 times more likely to have a negative case outcome.

CONCLUSION Network assessment appears to result in higher rates of positive case outcomes compared to the average for asylum seekers seen in the Atlanta circuit court. Areas for programmatic improvement include systematic followup and increased community awareness of Network services, since the Network may directly impact future case outcomes by offering assessment to more asylum seekers. Access to English language instruction and legal representation for asylum claimants may also contribute to more cases with positive outcomes.

KEYWORDS Refugees, United Nations High Commissioner for Refugees (UNHCR), vulnerable populations, transients and migrants, human rights, human rights abuses, torture, PTSD, USA