Advancing the Global Health Agenda: World Health Organization Collaborating Centers in Cuba
Gloria Giraldo, MPH

July 22, 2008 - The World Health Organization promotes health research through a system of 944 Collaborating Centers spread across the globe in 99 countries. More than half of these centers, however, are concentrated in just 15 countries, mostly in the Global North.[1] Among developing countries, Cuba stands out with 10 Collaborating Centers, the third largest number in Latin America and the Caribbean, after Brazil, with 23, and Argentina, with 11 – one more testament to this small nation’s world-class scientific research institutions and their contributions to improving health on a global scale.

What are Collaborating Centers?

In 1949, delegates to the World Health Organization's Second World Health Assembly were faced with the question of how the organization could best promote health research. Delegates agreed that “research in the field of health is best advanced by assisting, coordinating and making use of the activities of existing institutions” in the member states.[2] They ultimately decided that WHO would not establish its own international research institutions but instead form collaborative relationships with local institutions in member nations.

Institutions that have attained international recognition for important scientific achievements and technical capability may be named WHO Collaborating Centers. After consultation with the national government and institutional heads, a Collaborating Center designation is made for an initial term of four years. The designation is renewable and is independent of WHO financial support for the institution.[2]

A Collaborating Center may be a department or a laboratory within an institution, or a group of institutions doing research of global interest to advance WHO’s programmatic objectives. WHO provides these centers with opportunities to network with their peers around the globe while helping to strengthen the institutional capacity of participating countries. Each of the Cuban centers belongs to an international network of Collaborating Centers working in the same field. For example, Cuba’s Center for Occupational Health is one of a approximately 70 institutions and organizations linked through a network of occupational health centers.[3] In addition, Cuba’s Ministry of Health has created a national network to strengthen inter-institutional knowledge, coordination and collaboration among the designated WHO Collaborating Centers and other research institutions designated “Centers of Excellence” by the Cuban government.[G. Marquina, interview, March 27 2008] [4]

Cuba's 10 Collaborating Centers cover a range of diverse fields from malacology (the study of mollusks) to health informatics. The Center for Research in Human Reproduction was the first to be designated, in 1976; the most recent is the Center for the Development of the Virtual Health Library, designated in 2005. Each Center is part of a major national public research institute, as shown in Table 3. Cuba Health Reports visited several of Cuba’s Collaborating Centers and interviewed some their directors about their collaboration with WHO.

WHO Collaborating Centers at the Pedro Kourí Institute for Tropical Medicine (PKI)

WHO Collaborating Center for Research and Training in Medical Malacology and Biological Control of Vectors and Intermediate Hosts
The work of this center revolves around conducting basic science research to develop comprehensive biological vector controls utilizing a variety of organisms, including mollusks, plants, larvivorous fish and parasitic nematodes. “Our research seeks to improve biological control of vectors and apply these new technologies in the field. We are also simultaneously training personnel from countries in our region and beyond,” explained Israel García Avila, a lead researcher at the center. According to the specialized literature, formulations of bacteria such as Bacillus thuringiensis israelencis, have become predominant non-chemical means of controlling mosquito larvae in many countries.[5] The center’s research has led to the manufacture of the biological larvicides Griselef® and Bactivec®, which target mosquitoes and flies that transmit dengue and other diseases.[6]

WHO Collaborating Center for Virology
This center functions as Cuba’s national reference laboratory for viral diseases, including rubella, measles, mumps and polio. Since becoming a Collaborating Center in 1994, it has extended the scope of its work to include all of the respiratory viruses as well as enterovirus, hepatitis, rotavirus, rabies, West Nile, Human Papilloma Virus (HPV) and HIV.

The Center for Virology has also studied an injectable polio vaccine using an inactive virus which could replace the current attenuated live virus oral polio vaccine. According to PKI Director, Dr Gustavo Kourí, the Pan American Health Organization has applauded the study as an important advancement with implications for polio eradication strategies worldwide.[G. Kourí, interview, Dec. 27, 2007]

WHO Collaborating Center for Tuberculosis (TB) and Other Mycobacteria
This Center is part of Cuba’s National Tuberculosis and Mycobacteria Reference Laboratory, which also oversees the national health system's laboratory network. As a Collaborating Center the institution serves as a regional reference laboratory for quality control of direct examination of sputum smears for acid-fast bacilli, and also participates in WHO-sponsored international Multi-Drug Resistance (MDR) surveillance programs. According to Dr. Ernesto Montoro, co-director of the Center, Cuba is the only Latin American country that has participated in the three global Multi-Drug Resistance (MDR) studies.

The Center is committed to developing new methods for diagnosing TB resistance, reviewing technical guidelines for laboratory diagnostics in the region, and developing international courses on TB control. For example, the Center recently provided consulting services to the Dominican Republic’s Ministry of Health on its efforts to build laboratory capacity in preparation for the country’s first national MDR-TB survey.

Dr Montoro also explained that Cuba is participating in international research on TB eradication with the long term goal of eradicating TB in Cuba. Cuba’s implementation of the Directly Observed Treatment, Short-Course (DOTS) strategy has resulted in cure rates of over 90% and low attrition rates. In 2006, TB incidence in Cuba was 6.2 per 100,000. “We are well positioned to eliminate TB in Cuba, and the center will continue to work to advance that goal,” concluded Dr Montoro.

WHO Collaborating Center for the Study and Control of Dengue
This is a multidisciplinary center staffed by scientists from PKI; the Institute for Hygiene, Epidemiology and Microbiology (INHEM); and Provincial Anti-Vector Surveillance Units. Together they study the social, environmental and biological conditions that influence the transmission, control and treatment of dengue.

“Due to several factors, among them dramatic climate change, dengue is emerging as the main cause of morbidity and mortality caused by an arbovirus (a type of virus transmitted by a blood-sucking insect). Studying this disease is of paramount importance for global health,” Dr José Luis Peregrino, co-director of the Center, told Cuba Health Reports. The Center’s holistic approach to the study of dengue requires an interdisciplinary team made of virologists, immunologists, epidemiologists, entomologists, sociologists and clinicians.

One of the Center’s major projects is the biennial International Dengue Workshop, which in 2007 attracted over 300 participants from over 40 countries. The center is engaged in international collaborations to develop vaccine candidates, as well as evaluation of a pediatric vaccine and an early diagnosis system. The Center also serves as a regional reference laboratory for external quality control for proficiency tests of dengue serological diagnosis.

Collaborating Centers at the Cuban Endocrinology Institute

WHO Collaborating Center for Research in Human Reproduction
This Center is charged with increasing the availability of high-quality family planning services and improving the provision of quality maternal and newborn health services.[7] The Center’s activities include studies on sexual and reproductive health from a social science perspective. Current projects include a study of male attitudes about sexual and reproductive health and behaviors. Another study is examining receptivity of new contraceptive methods. The Center also reports participating in a study examining the impact of second medical opinions in reducing the number of cesarean sections.[8]

WHO Collaborating Center for Integrated Medical Care Services in Diabetes
This national reference center for diabetes care sets the guidelines for comprehensive diabetes care throughout the country. Its model of care brings together endocrinologists, nutritionists, ophthalmologists, podiatrists, psychologists, health educators, medical educators and nurses to work on screening, early diagnosis, treatment, education, and prevention of complications. The Center is active in the training of health professionals specializing in diabetes care.

Additionally, the Center guides the nation’s diabetes research agenda. “Previous studies have shown that for each known diabetic in the country, there is at least one undiagnosed patient. Finding pre-diabetics is essential to controlling the disease,” emphasized Dr Oscar Díaz, director of the Endocrinology Institute. The Center is currently working with family doctors to carry out an exhaustive screening program in the municipality of Jaruco, Havana Province (pop. 25,000), to identify pre-diabetics and diabetics, and evaluate the health system’s success in improving diagnosis. Preliminary results of the Jaruco study show that about 20 to 30% of all diabetics in the municipality were undiagnosed, a major improvement over a previous study in another location, 5 years earlier, which reported 50% of diabetics undiagnosed. “Thus showing that there is a lower occult prevalence of diabetes and allowing the health system to better deal with real rates of the disease,” concluded Dr Díaz.

Table 3: WHO Collaborating Centers in Cuba

Collaborating Centers at other institutions

WHO Collaborating Center for Occupational Health
Based at the National Institute for Occupational Health, this Center is charged with conducting research on occupational respiratory diseases, occupational diseases in the agricultural sector, industrial neurotoxicity, ergonomic and work capacity, and the organization of occupational health services within the national health system.[9]

WHO Collaborating Center for the Development of Genetic Approaches for Health Promotion
The National Medical Genetics Center was founded with the principal aims of controlling genetic conditions, such as sickle cell anemia and Down Syndrome. The Center also provides alphafeto protein (AFP) screening and genetic counseling for pregnant women over 38 years of age to help prevent birth defects. In 2003, the Center implemented a seminal national epidemiological study on disabilities and genetic diseases.

“One of our main goals is to not only train the health work force, but also educate the population, so that people learn about and understand their risks, and access services appropriately,” explained Dr Beatriz Mancheco, director of the Center. Today, the Center offers a national health system model for making genetic services available to the entire population by integrating them into primary, secondary and tertiary health care. Everyone in Cuba has access to genetic counseling and medical options at every level of care, from genetic counselors at the policlinics to medical specialists at hospitals. More than 600 Cuban family physicians have obtained advanced training in genetic counseling and work in the 184 genetic centers throughout the country. As part of its commitment to WHO, the Center offers a Master’s program in medical genetics to Latin American health professionals and also trains cytogenetic technologists.

WHO Collaborating Center for Health in Housing
Part of the National Institute of Hygiene, Epidemiology and Microbiology (INHEM), this Center’s mission is to develop methods for monitoring and evaluation of interventions designed to create healthy homes. Some of the research projects include studies of electromagnetic fields, micro-climates, and the impact of noise on health.[10]

WHO Collaborating Center for the Development of the Virtual Health Library
This Center is based at the National Information Center for Medical Sciences, which hosts Infomed, the Cuban health internet network dedicated to the provision of updated medical and health information utilizing new information technologies.[11] The Center provides technical assistance to countries in the English-speaking Caribbean for planning, construction and launching a Virtual Health Library (VHL), as well as subsequent development, operation and evaluation. The center also trains local and international professionals in information management.

References:

1. WHO Collaborating Centres [homepage on the Internet]. Geneva: World Health Organization; c2008 [cited 2008 June 25]. Available from:
   http://www.who.int/collaboratingcentres/en/.
2. More on the Collaborating Centres [homepage on the Internet] World Health Organization; c2008 [cited 2008 June 25]. Available from:
   http://www.who.int/collaboratingcentres/cc_historical/en/index.html
3. More on the Collaborating Centres [homepage on the Internet] World Health Organization; c2008 [cited 2008 June 25]. Available from:
   http://www.who.int/collaboratingcentres/cc_historical/en/index1.html (Financial Stuff)
4. Network of WHO Collaborating Centers on Occupational Health [homepage on the Internet]. Geneva: World Health Organization; c2008 [cited 2008 May 25]. Available from:
   http://www.who.int/occupational_health/network/en/index.html
5. Red Cubana de Centros Colaboradores OMS [homepage on the Internet] Havana: Infomed; c1999-2006 [cited 2008 Mar 20]. Available from: http://centrosoms.sld.cu/.
6. Lacey LA. Bacilus thuringiensis serovariety isralensis and bacillus sphaericus for mosquito control. J Ame Mosquito Con Assoc. 2007; 23 (2): 133-163.
7. New Havana Plant to Produce Ecological Bio-Larvicide for Vector Control. Cuba Health Reports News Briefs [serial on the Internet]. 2008 May 13 [cited 2008 July 15]. Available from: http://www.medicc.org/cubahealthreports/chr-briefs.php?a=0&d=05/13/08
8. WHO Collaborating Centres Global database [database on the internet]. Geneva (Swe): World Health Organization. c2008 [cited 2008 Mar 20]. Available from: http://www.who.int/whocc/Detail.aspx?cc_ref=CUB-7&cc_code=cub&
9. Centro Colaborador de la OMS para la Investigación en Reproducción Humana - Red Cubana de Centros Colaboradores OMS [homepage on the Internet]. Havana: Infomed; c1999-2006 [updated 2007 Dec 5; cited 2008 July 15] Available from: http://centrosoms.sld.cu/carpeta-de-trabajo/centros-colaboradores/
   centro-colaborador-de-la-oms-para-la-investigacion-en-reproduccion-humana/
10. Centro Colaborador de la OMS para la Salud Ocupacional - Red Cubana de Centros Colaboradores OMS [homepage on the Internet]. Havana: Infomed; c1999-2006 [updated 2007 Nov 1; cited 2008 July 15] Available from: http://centrosoms.sld.cu/carpeta-de-trabajo/centros-colaboradores/
    centro-colaborador-de-la-oms-para-la-salud-ocupacional/
    centro-colaborador-de-la-oms-para-la-salud-ocupacional/.
11. Centro Colaborador de la OMS para la Salud y la Vivienda - Red Cubana de Centros Colaboradores OMS [homepage on the Internet]. Havana: Infomed; c1999-2006 [updated 24 Oct; cited 2008 July 15]. Available from: http://centrosoms.sld.cu/carpeta-de-trabajo/centros-colaboradores/
    centro-colaborador-de-la-oms-para-la-salud-del-hogar/
    centro-colaborador-de-la-oms-para-la-salud-del-hogar/.
12. Seror, AC. A case analysis of Infomed: The Cuban national health system telecommunications network and portal. MEDICC Review [serial on the Internet]. 2008 Winter [cited 2008 July 15]; 10(1). Available from:
    http://www.medicc.org/mediccreview/medicc-review-article.php?i=2&a=23