Headlines in Cuban Health
Cuban Med Schools Pilot Community-Based Curriculum

By Gail Reed and Julián M. Torres

Until this year, approximately 18% of the basic medical school curriculum in Cuba was carried out at the primary care level, that is, in the community, with teaching polyclinics at the hub of this university extension.

However, starting this 2004-2005 academic year, in the community is where a good share of Cuba’s medical students are receiving nearly all their learning - from basic sciences all the way through to clinical training. They are participating in the pilot experience of a new educational strategy under evaluation by the Ministry of Public Health, which in Cuba is responsible for all medical education.

“The idea behind this,” says Dr. Jorge Bacallao (1), who is charged with ongoing evaluation of the innovative approach, “is to take teaching to where the student will be practicing upon graduation. Or put another way: transforming community-based polyclinics into the students’ main site for learning.” Thus, according to the new plan, students will spend more time under the mentorship of specialists in family medicine and other primary care fields at the community level than they will either inside medical school classrooms or in hospital settings. However, designers of the program are quick to point out that this does not mean that courses in basic sciences will be trimmed, or that less depth will be required for rotations in clinical fields.

The main point, emphasizes Dr. Bacallao, is to “overcome the old contradiction that students whose future was in community-oriented primary care were being educated by professors trained in and passing on a medical culture based on hospital care as the main pillar of the health system.” In Cuba, there can be no doubt that the system’s main pillar is the network of family physicians and nurses, located in virtually every neighborhood in Cuba, and who provide preventive care, treatment, referral services to secondary care, and rehabilitation. (See MEDICC Review , Volume 6, No. 2, 20 Years of Family Medicine in Cuba, November, 2004). In general, medical students in Cuba are required to follow their M.D. with a two-year residency in family medicine (Medicina General Integral), before opting for a second specialty in any other medical field.

In Havana, some 50% of Cuban medical students have been tracked into the new plan of study; 40% are enrolled in the traditional curriculum; and 10% in a curriculum which mixes the two approaches. Each of the three groups is being followed to evaluate their academic results, in basic sciences as well as practical clinical skills and understanding. Dr. Bacallao notes that these assessments will be used to develop and institutionalize the more formal curricular methodology, definitions of clinical rotations at hospital level and other aspects as the program develops. “Similar strategies have been applied in other parts of the world, but mainly for other types of medical personnel,” notes Dr. Bacallao. “But as far as we know, the educational strategy we are implementing for physicians is unique to Cuba.”

(1) Jorge Bacallao, PhD, Full Professor, Higher Institute of Medical Sciences, Havana.

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More Graduates for Genetics Counseling Master’s Degree

By MEDICC Revie w Staff

From 2001 - when the Master’s Degree in Genetics Counseling was first offered - to the close of 2004, Cuba’s post-graduate program in the field awarded a total of 406 M.S. degrees to health professionals across the country. The objective is to turn out enough trained personnel to staff genetics counseling services in all 169 of Cuba’s municipalities, both at the primary and secondary care levels.

The 406 graduates include 341 family doctors, 56 nurses and nine professionals from other medical fields. Dr. Aracelis Lantigua, Academic Coordinator for the National Medical Genetics Center in Havana, heads the academic committee for this program, and noted that its purpose is “to offer advice to people who suffer from genetic illnesses and conditions; share knowledge with professionals responsible for attention to these people in each municipality; ensure the quality of antenatal and neonatal programs for prevention of genetically related conditions; and continue research in the field.”

The national network for diagnosis, management and prevention of genetic illnesses and conditions now includes some 600 professionals throughout the country. In addition to counseling, they have carried out studies on clinical and community genetics, immunogenetics, and genetics and ethics.

The program received additional attention and support as a result of the 2003 national study on disabilities, which assessed a wide range of both physical and mental disabilities, including mental retardation. During the study, led by current First Vice Minister of Public Health Marcia Cobas, virtually everybody in the country with these disabilities were visited at their homes, in order to reaffirm diagnosis and treatment protocols, as well as to assess other problems that they might have - whether strictly medical or social - and begin to offer assistance in that regard.

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New Facilities Boost Cuban Biotech

By Gail A. Reed

New plants opened at three of Cuba’s top research centers promise to multiply manufacturing capabilities for biotech products, including cancer vaccines for clinical trials in the USA and elsewhere (see MR story, “ US Company Licenses Three Cuban Cancer Vaccines ” ).

The new facilities are located at West Havana’s Scientific Park, a cluster of research, higher education and health care institutions devoted to biotechnology and vaccine development since the early 1980s.

Three of the plants are dedicated to producing clinical trial samples of the new Cuban therapeutic vaccine against lung cancer EGF-P64k, already being tested in Cuba and soon to be tested by the US firm CancerVax in the USA and Europe. Active ingredients will be obtained at two plants at the Center for Genetic Engineering and Biotechnology (CIGB), scheduled to go into operation in March, while vaccine production will be finalized at a facility at the Center for Molecular Immunology (CIM), which led development of the new vaccine. The vaccine has showed excellent results among 200 patients with advanced stages of lung cancer in Cuba and China.

Another new plant at the CIGB is dedicated to producing active ingredients for Cuba’s new vaccine against Haemophilus influenzae, “the world’s first human vaccine with a synthetic antigen for Haemophilus influenzae type b (Hib),” according to a recent article in Nature Biotechnology.

Production began in August, 2004 at this unit, which boasts an installed capacity of 10 million doses annually. The Hib vaccine is now included in Cuba’s national vaccination scheme, which protects Cuban children against 13 diseases, and the plant is expected to be certified by the World Health Organization in early 2006.

Other recent investments at the CIGB have doubled installed capacity for production of the Cuban recombinant hepatitis b vaccine, reaching nearly 6 million children’s doses annually, and dramatically increasing the potential for export from this facility already certified by WHO.

At the Center for Molecular Immunology (CIM), facilities have been expanded for production of erythropoietin (-α ), used for anemia in patients suffering from chronic kidney disease (CKD). The move will increase installed capacities from half a million to 6 million vials annually, easily covering the needs of Cuba’s health system and extending export possibilities. In December, Cuban scientists announced that investments in development of Cuban erythropoietin were completely recovered by the first sale of the product to Brazil.

At the nearby Finlay Institute, a plant was inaugurated in late 2004, where active ingredients for six vaccines will be synthesized, including those for tetanus and tetanus-diphtheria. Cuban Public Health, Dr. José Ramón Balaguer, speaking at the inauguration in early December, noted the facility’s potential for producing vaccines for Cuba and for other countries as well.

Dr. Concepción Campa: Keeping the needs of poor countries on Cuba’s research agenda

Dr. Concepción Campa, who directs this Institute at the hub of Cuba’s national vaccine research program, also spoke at the opening of the new building early in December.

She emphasized that Cuban researchers still have “a long way to go” to complete important vaccine research projects in the pipeline, including vaccines against dengue, hepatitis A and C, cholera, AIDS, tuberculosis and both pentavalent and tetravalent children’s vaccines. One of the singular characteristics of Cuban biotechnology has been its dual emphasis on diseases of the industrialized world and those of the developing world.

The latter suffers from the so-called “diseases of the poor,” which have been virtually eliminated from the research agendas of the giant pharmaceutical transnationals and the institutions they fund, earning them sharp criticism from Third World health authorities and the WHO itself. A second characteristic of Cuban biotechnology also contrasts with the general practice of these giants - modest pricing and a record of technology transfer to other developing countries.

Among the most promising of Cuba’s newer biotech products is the h-R3 monoclonal antibody (mAb) for use against head and neck tumors, which passed successful efficacy trials in Cuba, Canada and China. The h-R3 is now being registered in China and a joint venture company set up between the two countries has just finished construction of a monoclonal antibody production facility in China. Transfer of this technology has also been successfully negotiated with India, where efficacy trials for h-R3 are currently under way.

Internationally, Cuban researchers have filed some 500 patent applications in the health biotechnology sector, based on more than 200 inventions. Applications have been filed in the USA, throughout Europe, in India, China, and in Brazil and other Latin American countries. Cuba currently exports these products to over 50 countries (Nature Biotechnology).

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Water, Water Everywhere But Not Drop to Drink

By Conner Gorry

There's a particularly cruel type of impotency reserved for the moment you turn on a faucet and nothing happens. Not a gurgle or drip, no deep rumble in the pipes, nada. This is exactly what occurs in countless homes across Cuba every day; while the rest of the world confronts the most devastating natural disaster in recorded history brought on by too much water, Cuba is an ongoing struggle against the worst drought to hit the island nation in over 70 years.

Since May 2003, Cuba has experienced historically low levels of rainfall, with the eastern provinces of Camagüey, Las Tunas, Holguín and Granma suffering the brunt of what is known here simply as "La Sequía" (The Drought). According to Aymee Aguirre, Vice President of the National Hydraulic Resources Institute, between May and October 2004, Cuba had received the least amount of rainfall since 1931 - 54% of normal levels nationwide, dropping to a crippling 47% in the eastern provinces.

Furthermore, almost all of the 235 reservoirs across the country are at less than 25% of their total capacity. The picture is even grimmer in the provinces of Las Tunas and Camagüey, where reservoirs directly serving the population are barely at 20% capacity. This has necessitated the use of cistern trucks, giant water taps on wheels that visit neighborhoods, dispensing the liquid gold to hundreds of thousands of homes on regularly scheduled rounds; in some cases this is just once every 21 days.

Such extreme scarcity has engendered widespread conservation efforts to curtail water waste, an exacerbating factor cited by government officials and highlighted in nationwide public service announcements. Sealing dripping taps, upgrading pipe connections and other water-saving measures have become a priority among neighborhood associations all over the country. Additionally, the government has undertaken an aggressive water pipe building program which has been laying pipe intensively across Holguín to direct water from the Río Cauto to drought stricken areas. Providing the population with direct access to drinking water, hospitals, social services, and tourism, are among the areas prioritized for the liquid commodity.

In his annual report, Economic Minister José Luis Rodríguez estimated economic losses at US$823 million due to the drought. This comes on the heels of the estimated US$2.2 billion lost after Hurricanes Charlie and Iván hit the country in August and September respectively of last year.

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Infomed: Cuba's #1 Website

By Conner Gorry

It's the classic computer-dot com success story: a one-room office is armed with a couple of computers, a handful of modems, a great idea and the dedicated people to make it a reality. But this isn't MacIntosh or eBay, with the latest technology at innovators' fingertips and the profit motive as impetus. This is award-winning Infomed ( www.sld.cu), the Cuban health portal that connects health professionals across the globe, allowing them to jump borders virtually, facilitating information-sharing and fostering a collective knowledge in all areas of health.

From those humble beginnings in 1992, Infomed has blossomed into a network powerhouse that provides email to 30,000 health professionals in Cuba and provides a digital platform for a virtual medical library with entire ebooks, a bibliographical database, Cuban health statistics, medicine information and other materials. Infomed also offers continuing education classes, virtual conferences and daily health news. These services are available in every hospital and polyclinic across Cuba, allowing doctors, technicians and researchers to swap experiences and findings, consult on diagnoses and collaborate on research, improving overall health management of their clients.

Infomed, technically known as La Red Telemática de Salud Cubana, was recently ranked Cuba's number one website by Site Ranking (http://trafficranking.com). Furthermore, of the 900,000 most visited sites on the Web, Infomed ranks an incredible 6,700 in the world and 171 among Spanish-language sites according to Site Ranking. In 2002, Infomed won the coveted Stockholm Challenge Prize for life-improving information technologies.

Infomed's Vice Director of Technology, Carlos Manuel Reyes told MEDICC Review that the network has nodes in all the provinces, including the special municipality of the Isle of Youth, plus a national node in Havana. Although these currently lope along at a connection speed of 256k, Infomed hopes to ramp up to 2MB connections nationwide by the end of 2005, according to Manuel. The recent upgrade to fiber optic lines connecting the main Havana hospitals and the national and provincial nodes, will facilitate this process.

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By Michele Frank, M.D.

CARDIODEF 2 isa Cuban-made defibrillator/monitor which was officially introduced last fall at the 3 rd International Congress on Emergency Medicine and Intensive Care in Havana ( see “ Immunization and Vaccine Research in Cuba ” ) .

Initial clinical application at several cardiovascular services in Havana represents what is expected to be a rapid process of incorporation of the medical device throughout the health care system, including at the community-based, primary care level.

The equipment, used on patients with ventricular fibrillation and other arrhythmias, is a portable device, easy to use in ambulances and a variety of make-shift emergency service situations, in operating rooms, local clinics and doctor’s offices, and even outdoors during a disaster situation. The defibrillator is equipped with it’s own lighting system to ensure visibility and optimum utility under any conditions. In addition to a number of innovative characteristics, the CARDIODEF 2 includes an integrated monitor to enable visualization and continuous monitoring of the patient’s electrocardiogram. Such design elements are contributing to rapid acceptance and functional utility of CARDIODEF 2, according to initial reports and feedback from health care professionals working with the device.

The defibrillator/monitor, together with other interventions and procedures used in acute care cardiovascular emergency situations, is expected to significantly improve long term outcomes. Specialists in the field note the progress already being observed due to the use of the CARDIODEF 2 equipment in conjunction with Recombinant Streptokinase (Hiperkinasa), also developed and produced in Cuba at the Genetic and Biotechnology Engineering Center. The use of this Cuban bio-tech product has a solid record as a highly effective early-stage intervention due to its capacity to destroy clots affecting the blood flow of patients with myocardial infarction. Available throughout the health system, including at primary care, community-based emergency facilities, the Cuban Recombinant Streptokinase is readily accessible and has helped save many lives at a much lower cost than imported thrombolytic treatments. The combination of the new defibrillator and Recombinant Streptokinase is expected to impact indicators significantly through reduced mortality.

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By Michele Frank, M.D.

UNPF Director Thoraya Obaid, members of her delegation and UN resident coordinators during the UNPF Cuban visit.

Thoraya A. Obaid, Executive Director of the United Nations Population Fund (UNPF), visited Cuba for the first time in December. In statements made to the press, Obaid said: “What I have seen in Cuba in the health field, in the field of sexual and reproductive health, and in education are like nothing I have ever seen before – this is a phenomenon I have not witnessed in any other country I have visited.”

 Obaid underlined the fact that in Cuba the great majority of children go to school, that the health care system is universal and free of charge, and that the incidence of HIV/AIDS is remarkably low. She emphasized that this is due to the extraordinary organizational measures and initiatives of the Cuban government, to the unprecedented leadership role that the government has assumed in this regard. “No other country has done anything like this,” she said.

The UNPF director also acknowledged the significance of Cuba’s positive health indicators and population statistics, including those relating to development opportunities for women and advances made by Cuban women and the role of the UNPF in supporting this process. Obaid went on to express UNPF's interest in broadening it’s support and the intention to further develop work in the areas of health and health promotion, particularly with regards to issues of sexual and reproductive health among adolescents.

In addition to a wide range of visits, the UNPF director met with representatives from the Federation of Cuban Women, the Ministries of Education and Foreign Relations as well as the Ministry of Foreign Investment and Economic Collaboration.

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Cuban Immunization Program Receives PAHO’s Highest Rating

by Michele Frank, M.D.

Officials of the Pan American Health Organization’s Expanded Immunization Program (EPI) bestowed its highest rating on Cuba’s national immunization program after completing an in-depth inspection and evaluation of the island’s vaccination and immunization system. See Spotlight: “Cuba’s National Immunization Program.”

Dr. Jon Kim Andrus, PAHO/WHO Director for Immunization Programs

“The quality, organizational consistency and systematic application of the Cuban Immunization Program is impressive and significant,” commented EPI director, Dr. Andrus, who was trained in family medicine and holds degrees in Epidemiology and Public Health, as well. The international team stressed the importance of disseminating the Cuban experience to the rest of the world. Dr. Andrus emphasized that “…the Cuban people and Cuban health officials obviously understand [the] program and achievements and are conscious of the significance of this at many levels. However, for us, the most important thing - what is most needed at this point - is that this work, these results, be communicated and disseminated to other countries.” Andrus reiterated his team’s praise of the significant degree of coverage seen throughout the country and pointed out that in Cuba the risk of re-introduction of preventable disease is basically nil. Finally, Dr. Andrus thanked the Cuban Health authorities for “…giving us the opportunity to learn from you, to learn the lessons of your experience.”

The prestigious evaluation team representing PAHO and the World Health Organization (WHO) was made up of top experts in the field including

Jon Kim Andrus, who directs the Washington, D.C.– based PAHO/WHO Immunization Unit; Mauricio Landaverde, PAHO Regional Advisor; Rosario Quiroga, Bolivian Vice-Minister of Public Health, along with Lea Guido, former Nicaraguan Minister of Health and currently the WHO/PAHO representative in Cuba. The team visited national institutions, agencies involved in cooperation efforts, as well as hospitals, municipal and community-based health facilities, neighborhood clinics, laboratories, warehouses, and schools. The evaluation analyzed immunization levels among 36.4 % of the population.

In 1962, Cuba was declared the first territory free of poliomyelitis in the Americas. This achievement was followed by the eradication of measles, rubella, and mumps. Likewise, the Cuban population is protected against congenital rubella and all the major forms of meningitis, among others.

Cuban children are immunized against 13 different illnesses, in most cases with Cuban-produced vaccines, including type B Haemophilus influenzae (HIb), the new Cuban synthetic vaccine, the only one of its kind; see “Cuba Demonstrates Effectiveness of its Haemophilus Influenzae Vaccine.” Cuba boasts 98% coverage through a community-based program implemented by the public health system involving family doctors and nurses at the neighborhood level as well as in the schools. This rate of coverage has been achieved by very few countries, including the United States, where more than two million infants do not complete that country’s full recommended immunization schedule and thousands more have never been inoculated against any disease.