MR INTERVIEW

Roundtable with Two Generations
of Cuban Nephrologists

By Michele Frank, MD, with MEDICC Review Staff

Cuban nephrology’s “founding fathers” sat down with the specialty’s new blood to discuss the history and trajectory of nephrology in Cuba, the importance of prevention, research and an integrated approach and what makes a good nephrologist. Convened by MEDICC Review at the national Institute of Nephrology in Havana, participating in the round table were Dr. Reynaldo Mañalich, Dr. Charles Magrans, Dr. Roxana Fraga and Dr. Christian Leyva.

Drs. Mañalich and Magrans, both nephrologists, professors and researchers, are two of the specialty’s pioneers in Cuba, while Drs. Fraga and Leyva are residents-in-training for what will be their second specialty, since both completed residencies in family medicine and worked as community-based primary care physicians before coming to the Institute. Given the presence of two of the architects of modern Cuban nephrology, we took the opportunity to begin by talking a little about the specialty on the island.

MR : How has this specialty been able to integrate the changes in focus that have come about as the Cuban health system has evolved? Historically how have these changes developed and what role does prevention play?

“We began to realize that our biggest challenge wasn’t treating ARF, but rather preventing it,” Dr. Charles Magrans.

Dr. Magrans : During the early years of the revolution [1960s, eds.], a working group was set up to try to begin to provide dialysis for the whole country...Initially three groups were established – one in the eastern part of the country, one in Villa Clara in central Cuba and one in Havana – all trying to develop ways to deal, primarily, with the problem of Acute Renal Failure (ARF) and it’s consequences, and kidney disease in general.

We were internists, internal medicine specialists, not nephro-logists. Nevertheless, we began to dialyze patients and to treat ARF. By 1961 or 1962, we began to realize that our biggest challenge wasn’t treating ARF, but rather preventing it - preventing renal disease and other, often underlying, pathologies which lead to Acute Renal Failure…In order to be able to do prevention, we had to delve deeper into causes - sepsis for example. This is how nephrology as a specialty began to develop, and we were always pushing ahead, aiming to organize ourselves and the work better…One of the most important contributions made by Dr. Buch [founder and first Director of the Institute of Nephrology, Honorary President of the Latin American Society of Nephrology and the Cuban Society of Nephrology, eds.] was his extraordinary ability to motivate the people who worked with him. And I’m not just talking about other doctors, but also nurses, technicians, the whole group – we were very, very integrated and dedicated and we worked day and night – it was intense and the level of commitment was extraordinary.

We began to think, next, about the importance of training nephrologists in Cuba. So by the end of the 1960s, we were looking for ways to improve the training, improve the curriculum and just generally upgrade the whole specialty. Also, up to that point, nephrology-as-a-specialty was basically a matter of services for patients with acute disease. Then we began to work with chronic patients - fundamentally using periodic dialysis and beginning to look into renal transplantation.

In 1968, the Ministry of Public Health designated two people to study nephrology as a specialty in its own right. We put together a curriculum, a training program, based on visits we had made to other countries and on international exchanges that were taking place - with France, for example. So this is how our first specialists were trained. This quickly led us to begin thinking much more seriously about transplantation, especially now that we were having such positive results keeping people alive with dialysis. The first Cuban kidney transplant took place on February 24, 1970 and we were tremendously lucky because everything turned out well, the results were good; it was a successful transplant. That year we did 14 transplants.

MR : Your generation really created the Cuban “school of nephrology.” What have been the most important models and contributions to this effort, both nationally and internationally?

The Cuban “school of nephrology” grew and developed rapidly because of the principle of universalization of care, according to Dr. Reynaldo Mañalich.

Dr. Mañalich : From my point of view, there are several key “moments” or elements that are particularly important. One of these is that Dr. Buch, Dr. Magrans and myself had the opportunity in 1957 to take part in a very significant event that was Dr. Willem Kolff’s visit to Cuba. Dr. Kolff, a physician from Holland, was the creator of the first artificial kidney and he gave a very important presentation here at the hospital where the Institute is now located. Also very significant in relation to the development of nephrology in Cuba was the assistance and collaboration offered by Dr. Jiri Jirka of Czechoslovakia – he was instrumental in helping to build the foundation of what would become our specialty, [introducing] us to a much broader view and scope of nephrology, beyond just dialysis and transplants. The other important aspect is the role that Dr. Buch played in all of this. Because of him, I believe, we were able to capture the attention of the Ministry of Public Health and the Minister at that time, who was Dr. Ramón Machado Ventura. Dr. Machado Ventura had phenomenal vision - for example, he created the research institutes of the Ministry of Public Health, including the Institute of Nephrology - with just three people!

Back then, at the very beginning, our patients came from all across the country because there wasn’t any other place where they could get dialysis…The amazing, and perhaps most important, thing about all of this - thanks to Dr. Buch’s vision - is that the development of nephrology in Cuba was not limited to the Institute. He worked hard to extend these services to other hospitals in Havana and also to the pediatric hospitals. It was with pediatrician Dr. Santiago Valdés Martín’s participation that pediatric nephrology was born in Cuba.

So, nephrology reached other hospitals, other provinces, right from the beginning, and the numbers of nephrologists have been growing steadily. Right now, there are 280 nephrologists and 150 residents in training throughout the country.

I guess you could say that we were the seeds – it started here with us - but it grew and developed rapidly because of what I like to call “the Buch principle” which was the principle of “universalization” of the specialty. He had a very clear vision in this regard and pushed for it. This, of course, dovetails very well with Cuba’s commitment to universal health coverage. Now our challenge is to continue to broaden dialysis and transplant opportunities, to expand and further develop access throughout the country, and to thoroughly research the current health status of the population in this regard, to do an accurate needs assessment.

Dr. Magrans : I think the first fundamental concept is this idea, from the very beginning, of the “universalization” of care - that it should be available everywhere, to everyone in the country…But preventing Acute Renal Failure (ARF) from developing in the first place is the most serious and important task before us.

MR : How does organ donation work in Cuba? Is there an organ donor program?

Dr. Magrans : Organ donation has involved education mainly - an educational process guided by strict ethical principles. In the first place, this is considered a family decision, the family has to authorize it. At one time we actually had an organ donor program like some other countries where people registered so that their identification papers indicated they wanted to be donors, in case of an accident or whatever. This kind of thing isn’t so necessary any more here because people are much clearer on the issue - it has become almost a cultural thing, something natural or normal, whereby families just generally accept the idea of organ donation as a good and positive thing…Here in Cuba family members will donate an organ if it will save a life, if there’s compatibility. The majority of the kidneys used for transplant come from accident victims, and about 10% from relatives.

MR : Turning to the younger generation,as residents here at the Institute, what are some of the things that have most impressed you about your professors?

“There has been a notable rise in kidney disease: we need to understand this better, to go out into the community and pro-actively look for risk factors and study incidence,” Dr. Roxana Fraga.

Dr. Fraga : From the very beginning what I noticed most was how the professors are so committed, so intent on transmitting to us a sense of unconditional dedication…They have dedicated their lives to the development of this specialty in our country, but in addition they have been able to inspire us to feel great love for the work, for the patients, for the specialty. We understand that this specialty requires a great deal of sacrifice, dedication, scientific excellence, and passion - lots of passion!

Another thing that has had a big impact on us, I think, is that our professors have always tried to make sure that we understand the importance of being well-rounded, of being ‘integral’ or ‘integrative nephrologists’- meaning that we should be able to do everything, participate in, and understand, everything. We are being trained to be nephrologists who can look into a microscope, analyze a biopsy and together with the pathologist, present the diagnostic discussion; nephrologists who can be with a patient receiving hemodialysis and know all about everything that’s going on with the artificial kidney, including the mechanical or technical aspects; and, of course, we also are trained to know and understand which elements of a particular situation are important in terms of prevention, to understand risk factors.

The preventative approach is something we ourselves bring to the specialty: we know a lot about the base, the community, and how to analyze health situations with an eye to prevention, because we were family doctors before coming here. [Virtually all Cuban physicians must first complete a residency in family medicine before going on to a second specialty, eds.]. We understand how to look for risk factors and how important this can be. There has been a notable rise in kidney disease: we need to understand this better, we need to go out into the community and pro-actively look for risk factors and study incidence.

Finally, I would say that our professors have been really great about helping us find good bibliography so we can really study and keep up-to-date in terms of the medical literature in our field. This is important in any field of medicine, but I think in ours especially, because of both this rise in incidence on the one hand and the need for new or innovative approaches on the other.

“I think the most important contribution Cuba has to make is related to our preventive focus,” Dr. Christian Leyva

MR : What do you think Cuba’s role or contribution should be internationally to the field of nephrology, particularly for other developing countries?

Dr. Leyva : I think the most important contribution Cuba has to make is related to our preventive focus, given the particular characteristics of the Cuban health care system. Perhaps we do not have the most advanced technology or diagnostic equipment, for example, but with regards to prevention programs, early diagnosis, the “universalization” of health care delivery...in these aspects, I think we have something special to offer the international community. In fact, we are carrying out a major research project in this respect. It’s taking place on the Isle of Youth and perhaps from this we will be able to develop something that will not only benefit Cuba but that will be our contribution to the world. [For more, see “Cuban Studies Aim for CKD Prevention,” this issue.]

MR : What does it take to be a good nephrologist?

Dr. Leyva : In the first place, to be a good nephrologist, you have to be a good doctor. Nephrology involves all aspects of medicine - from the psychological to the organic. So the first and most important thing is, you have to be a good doctor. And not just from the point of view of the kidney: you need to study cardiology, psychology, etc. For example, the first to confront the problem of depression of the immune system were nephrologists, yet this is something that is apparently outside our area of expertise, but in fact that’s not the case. And there are a number of areas like this. You have to be able to integrate knowledge, to think! Thinking, analysis, the process of thinking things through and integrating information and knowledge, are fundamental to becoming a good nephrologist.

Dr. Fraga : I think it’s key to understand the importance of all aspects of nephrology. I mean, the prevention aspects are just as important as a timely diagnosis, for example, which is just as important as the treatment plan and adequate follow-up. You want to guarantee that hemodialysis goes well, you want to ensure the best possible preparation of the patient who is going to have a transplant...and then follow-up is very important too. Just like every patient should be given equal, totally dedicated attention: it’s what they deserve, it’s their right.

Dr. Magrans : I think this specialty has a particular characteristic in that it permits you to help patients continue to live, it’s a specialty that can keep people alive, for years even. The kidney as an organ is very important in this regard and the fact that we can maintain those functions, even artificially, is one of the things that gives nephrology its special and unique character.

For example, in Cuba the latest statistics indicate that 111 patients per one million inhabitants begin dialysis last year. We see them constantly, continuously, so we become like one big family…Imagine a patient who comes in for dialysis for four hours, three times a week over the course of, say, 10 years. This is a relative! This is a family member for all the people who work here. This is what makes for the human part of this work; it leaves it’s mark, believe me…The chronic patients nourish our humanity, they sensitize us in a way that makes us want to work more, dedicate more time, more energy, more effort…This is what I think is the mark of a good nephrologist. You see these patients, these people, you treat them, and the humanitarian aspects are what motivate you. It generates interest and a desire to study more, learn more – to try to resolve the problems. I think this is a characteristic of our public health system in general. So you think in human terms. For example, you worry about the cardiac patient, or any patient, not having to be transported great distances, being able to be closer to home…bringing health care as close to where people live and work as possible, into their communities, this is a general concern and responsibility throughout the public health system. [See “Bringing Services Closer to Home: MR Visits a New Dialysis Center in Cuba,” this issue.]

Dr. Mañalich : And looking at it from yet another angle, it seems to me that good nephrologists should be good specialists in internal medicine, or good pediatricians. Nephrology relates to all the body’s systems and you have to be knowledgeable in terms of liver disease, heart, lung, the brain…You have to have an integral approach and profound knowledge of many, many aspects of medicine, whether it’s endocrinology, immunology or cardiology. The nephrologist needs to be well versed in all of these because you can’t be sending the patient off to this specialist and that specialist. The patient isn’t a sum of different little parts with each part receiving separate, isolated attention from different medical specialists. It doesn’t work, in my opinion, in any setting, but in nephrology it definitely doesn’t work. To be a good nephrologist, you have to be able to see the whole patient, the whole person.