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MR FEATURES Training an Eye on Epidemics: As director of Cuba’s Health Tendencies Analysis Unit, (UATS according to it’s acronym in Spanish), Dr. Rodríguez Milord is responsible for overseeing the nationwide system of surveillance coordination, analysis and strategy designed to protect public health. The system directed by Rodríguez Milord forms a part of the Ministry of Public Health. He sat down with MEDICC Review recently to discuss his work in relation to epidemics, pandemics and the history of UATS. UATS was founded in the middle of the neuropathy epidemic that blindsided Cuba between 1992 and 1993 ( International Workshop on Neuropathy Epidemic in Cuba: Report Summaryand Cuba’s Epidemic-Fighting Model). As the crisis worsened – more than 50,000 Cubans were eventually stricken with the disease – it became evident that the country needed a better integrated, multi-sector surveillance system that could predict, analyze and respond to health threats in a coordinated, sustainable way. Dr. Rodríguez Milord was part of the specialist team in 1993 that conceptualized how that system could work. “What was so interesting about this was that we had to work inside of the epidemic, while it was happening, to track its progress and fight against it to protect the population’s health. But at the same time, we had to analyze how to design and implement a methodology and surveillance system,” Rodríguez Milord told MEDICC Review. In those early planning and response stages, the designers of UATS agreed that an efficient, effective surveillance system required:
Based on the experts’ collective experience, consensus was also reached on one of the guiding principles of the Cuban surveillance model, namely that the system be integrated both horizontally among vested health institutions and mass organizations, and vertically between those institutions and the people they serve. All of this was to be coordinated on a national, provincial and municipal level by a network of centers located throughout the country. UNICEF and PAHO were important initial supporters of this work. With the guiding principles in place, Cuba looked internationally for knowledge-sharing opportunities that could provide insight into how to structure such a system. “From the inception of UATS we worked with a diverse group of international agencies and specialists from Paris, Liverpool, Panama, Mexico and elsewhere,” explained Dr. Rodríguez Milord. “We also worked with the CDC in Atlanta, looking at how they designed their surveillance system and analyzing how to design and improve ours.” Not surprisingly, this international cooperation continues today in scientific exchanges like the one between Harvard’s School of Public Health and Cuba’s Pedro Kourí Institute of Tropical Medicine, which has US and Cuban researchers collaborating on epidemiology research of dengue, acute respiratory infections, hepatitis and others. In this age of facile plane travel, increased international trade, porous borders and globalization of everything - including emerging diseases like West Nile, hanta and Ebola viruses to name a few - international cooperation and vigilance of emerging threats are key to any public health system. Indeed, a cornerstone of the epidemiological surveillance work coordinated by UATS is surveillance beyond Cuba’s borders, emphasized Dr. Rodríguez Milord. “At every turn, our surveillance system has to be a national model with more international relevance; a more global system that works within our context and needs, but responds to global developments as well. In this sense, surveillance becomes part of our national defense system,” he said. The key to that surveillance is a three-pronged model divided into tactical, strategic and evaluation (Figure 1) modules. The purpose of the Action Alert System is to provide continuous, timely information on acute health events both nationally and internationally in order to identify, control and forge solutions to health risks. Using a methodology of active and intensive surveillance, this system allows for rapid response when faced with unusual or unexpected threats or those requiring priority or ongoing monitoring. The strategic aspect of the system is critical for designing effective, targeted health interventions. Along with projections, the key to this is the stratification of epidemiological data, which renders a clearer picture of a how health risks behave within a population. Collecting and analyzing that data requires an extraordinary level of coordination between national, provincial and municipal specialists, which isn’t always easy given the country’s limited resources. Cuban specialists in each province generate annual predictions based on historical antecedents, the expected behavior of a health risk and the current situation on the ground. In turn, these findings are prioritized and synthesized into a national prognosis. “Of course, certain factors can and will change,” says Rodríguez Milord, “but the statistical information, analyzed and interpreted by experts, and the history of a disease, are key to the scientific basis of any prognosis, which is a process, by the way, not a document.” Figure 1: Cuban Health Surveillance Model
Measuring the impact of that process through evaluation and affecting changes to improve the process and outcomes is the final link in the surveillance cycle. This is crucial for constructing a sustainable public health surveillance system, emphasizes Rodríguez Milord, especially as Cuba institutes system-wide changes to health care delivery including moving services closer to patients, retrofitting and upgrading hospitals and clinics, and consolidating prescription medicine programs. From the first alert to evaluation, the entire system relies not only on public health institutions, but also on every institution and its specialists that may lend expertise to the health risk in question - geographers, meteorologists, veterinarians, ecologists, etc. Moreover, the active participation of the population is integral to the success of the Cuban system. Says Rodríguez Milord, “Our model is based on integration, cooperation and participation between all disciplines and institutions in the function of public health…and there is no public health without political will on the part of the government.” But it doesn’t end there: each epidemic is a learning experience that presents an opportunity to improve the system, said Rodríguez Milord. During the hemorrhagic dengue epidemic of 1981 for instance, when 116,143 people were hospitalized countrywide, it became evident that Cuba needed more intensive care units (especially for infants), to provide the expected standard of care during an epidemic. Consequently, a plan to increase services and beds available in intensive care units and train the necessary staff, in pediatric hospitals particularly, was immediately implemented. In October, specialists from the world over will come to Havana to broaden that learning base, observing the Cuban model firsthand and imparting knowledge from their own experiences at the ‘Health Surveillance 2005’ conference, convened by the Pedro Kourí Institute of Tropical Medicine (www.ipk.sld.cu) and UATS. Daniel Rodríguez Milord , MD, PhD, is Director of the Unidades de Análisis y Tendencias en Salud, Professor and Associate Researcher at the Higher Institute of Medical Sciences, Havana. Notes & References:
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According to estimates by the Centers for Disease Control and Prevention, the next influenza pandemic could cause 2 to 7.4 million deaths worldwide, mostly in developing countries. Findings in The Lancet, meanwhile, peg global deaths in 2004 due to malaria, HIV/AIDS and tuberculosis at around 6 million.[1] Given these dire realities and prognoses, it’s no wonder Dr. Daniel Rodríguez Milord classifies surveillance of health threats as “part of our national security.”[2]