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MR INTERVIEW Gustavo Kourí, MD, PhD Continuing the work of his father, the late Dr. Pedro Kourí, Gustavo Kourí has transformed the IPK complex into one of the field’s top institutes, research centers and treatment facilities. A world-renowned hub of scientific activity, IPK has a record of continuous outstanding achievements and plays a key role in the training of the Cuba’s future scientific and medical professionals. MEDICC Review : Perhaps we could start with some history: could you speak about your background and what this institution does? Gustavo Kourí: Well, I have been around for quite a long time now! I was part of the first group of doctors and scientists, after 1959, to engage in serious scientific research. We set up the first scientific research center and worked on multiple projects at the same time. MR : So this institution has been responsible for confronting important challenges. How do you evaluate the progress in terms of the epidemiological situation in Cuba? GK: It is my opinion – speaking about our objectives – that we have met our goals. In the first place, in today’s Cuba, epidemics are very limited. For example, we sometimes still have influenza (flu) epidemics. These are situations that need to be confronted quickly, through good epidemiological surveillance and with vaccines. I’d say that this is an important goal at the moment – dealing with flu, with acute respiratory infections (ARIs). They are prevalent here and all over the world. MR : Do you mean ARI epidemics? Or do you mean outbreaks? Are there flu outbreaks that are considered important from an epidemiological point of view? GK: That depends on what you consider an epidemic. The concept of an epidemic is when there’s a notable rise in cases as compared to what is “normally” the situation. But if you’re talking about a situation where the norm is that there are no cases and then one case appears, that – technically – is an epidemic. One case of a disease that has been eradicated or that doesn’t exist in the country would be considered an epidemic. We don’t call it that: we usually refer to it as an epidemic outbreak or a localized outbreak, but really it is an epidemic because it’s a “new” disease registered in the country. This is the concept, and it reflects our approach – the Cuban approach. It’s one of the things that distinguishes Cuba from other countries. Worldwide, more than 13 million people die from infectious diseases every year, and one death in three is due to infectious or communicable diseases. The main causes of these deaths are influenza and pneumonia, (ARIs) first, then HIV/AIDS, malaria, tuberculosis, and measles. MR : So ARIs are the most important in terms of mortality and morbidity? GK: Yes, ARIs are killing many people in the world every day. The next most important killer is HIV/AIDS. And the thing is, almost all of these deaths occur in the non-industrialized world, in the poorer countries… The difficulty with ARIs is the issue of vaccines – or rather vaccine availability, access to the vaccine, to flu shots. If we could count on an efficient vaccine, then the numbers of cases would go down. With HIV/AIDS it’s a different story – it’s much more complex – because there is no vaccine and because it’s a disease that’s transmitted sexually or by injections; it’s a blood-borne infection generally, and an autoimmune disease, so it’s a very different and more complicated issue in terms of finding a vaccine. The situation internationally is really critical: there are entire countries - in Africa, for example - which are condemned. They are likely to just disappear, countries with infection rates of 40% of their population or more. When you think about all of this, when you analyze this situation and see it in terms of how health inequality not only affects the way people live, but also dictates how and at what age they die, it becomes evident that economics constitute a critical component of the problem. It all boils down to the issue of willingness to do anything about this crisis. We’re talking about preventable diseases. And another thing, infectious diseases affect children more than anyone else; the resulting childhood death rates are disproportionately high. Respiratory diseases kill enormous numbers of people every year. MR : In Cuba as well? GK: In Cuba we have some influenza or flu, we have some pneumonia, but there is a political will to seriously confront this. Still, we have a problem and we are working towards more and more extensive vaccination campaigns. If I’m not mistaken, this year we’re going to begin to vaccinate everyone over 60 years old for flu. As soon as we can - when we can get more vaccines, when we can get financing – we’ll begin to lower this age, and we will be offering this to more and more people. Influenza and pneumonia are the fourth cause of death in Cuba. Our health indicators are similar to first world countries, and our top 10 causes of death are basically the same. So number one on the list is heart disease and/or cancer – they go back and forth in terms of which is number one - followed by cerebro-vascular diseases, influenza and pneumonia, then accidents. So we have a very low mortality rate from infectious diseases, with the exception of influenza and pneumonia. If you leave this out, 0.9% of all deaths are due to infectious diseases – less than 1% for all infectious diseases combined. If you include influenza and pneumonia, then the mortality rate is about 8%. This is not that high, but still it’s significant. It concerns us. MR : How does Cuba deal with this? GK: We have an epidemiological surveillance system, a national network, monitoring for early detection – especially for infectious diseases like dengue and malaria (Training an Eye on Epidemics: Cuba’s National Health Surveillance System). We are also keeping a close watch on dengue and working very hard to control the situation to prevent an epidemic. In terms of infections, the status is very favorable. In Cuba children are immunized for 13 different illnesses. I would say that besides being favorable, this is unique, exclusive to Cuba. MR : Could you elaborate? GK: Because vaccinations are universal and free of charge. The other thing is that anyone who needs further protection gets it. The leptospirosis vaccine is an example of this – some people need it, because of their work or where they live. But all children get the basic 13, along with the appropriate booster shots and all that. This is unique, unusual, exclusive, as I said before. I’ve been to 45 countries and I can tell you that no other country has this degree of protection; there is no other health care system like this one. MR : And part of this, clearly, has to do with human resources. Could you speak to this point and perhaps share your thoughts on training? GK: Training and/or the formation of human resources is the determining factor for the development of a good health care system. I really do believe that human beings are absolutely fundamental and I think we are clear on this point here in Cuba: we have prioritized human resource development and professional training. In fact, we are even helping other countries in this respect – many other countries in a variety of ways. At IPK, the formation of human resources has always been a top priority. My entire career has been inextricably linked to teaching and mentoring - everything I do is science and human resources development. We have fully trained close to 3,000 students and young professionals from 72 countries and five continents at this institute. Altogether over the last 25 years, 28,000 people have received some form of training or continuing education here. We have a doctoral program, masters degree programs, and a wide variety of shorter courses of study; we even have classes and educational programs for children. Additionally, this August, we are offering our 9th International Course on Dengue, considered the best dengue course in the world, [see www.ipk.sld.cu for more information, eds]. Moreover, the IPK is now officially a WHO Collaborating Center for dengue. MR : Let’s talk about dengue and some of the history of dengue in Cuba. GK: We have information about dengue in Cuba going back to the 19th century, on the epidemic of 1828, for example. In 1977, there was a serious epidemic of dengue1, a real pandemic situation in the entire hemisphere and it was demonstrated that almost half of the Cuban population had been infected. Then there was the dengue2 epidemic of 1981. At that time, dengue2 was introduced into Cuba at several different locations and a very serious hemorrhagic dengue epidemic ensued. MR : Is it known for a fact that this was intentionally introduced into the country? GK: There is no solid scientific proof. There is scientific data and there has been research done. In the first place, dengue2 was not circulating in the Americas at that time. And secondly, it appeared suddenly and simultaneously in three separate locations: in the Havana City, in Cienfuegos and in Florida, Camagüey. When a disease is transmitted by vectors there is generally an initial illness focus. It’s inconceivable that in a matter of days, two other foci appear at distances of some 300 kilometers apart from one another, and practically simultaneously. More recently, we have the results of genotyping studies of the genome of the dengue2 strain. That genome had not circulated since 1947. It was generally considered to be a laboratory strain. I wouldn’t be surprised if one day documents turn up that show this to have been a deliberate biological aggression. There were 10,312 cases of hemorrhagic dengue fever (HDF). The worst epidemic of it’s kind to occur in the Americas…the 1981 epidemic breaks the epidemiological context. Before 1981 there were only 60 reported cases of HDF in the entire region. This is PAHO data. The epidemic of HDF in the Americas doesn’t really start until 1988-89. So this spike in 1981 is totally out of context, this is not natural. MR : This seems to indicate that there is currently a serious situation in terms of dengue in the Americas. GK: Yes, now it’s endemic to the region. Almost every country is reporting cases of hemorrhagic dengue fever, and this situation is sure to continue. MR : Are there recent publications by Cuban authors? GK: We have a lot of research written on dengue in Cuba. We did a review and update on the situation for The Lancet in 2000. The editors just recently sent us a letter of congratulations because this article is part of the 1% of most often cited publications on dengue in the world. We are currently preparing a CD, which compiles the hundreds of publications by Cubans for the upcoming dengue course. MR : And what about tuberculosis (TB)? GK: Our projection is to eliminate TB, which according to the WHO means fewer than 5 cases per 100,000. Our indicators are around 6.2%, so we are doing quite well. We need financing to do the necessary research and achieve the complete elimination of TB in Cuba; we would be the first country of the “South” and one of the few countries in the world to achieve this. We have a lot of advantageous conditions here to make this happen. For example, TB here generally responds well to antibiotics, unlike many other countries which have a high degree of multi-drug resistance. Also, we have the infrastructure to easily apply the Direct Observation Treatment (DOTS) method.
MR : Let’s switch to HIV/AIDS. What’s new on this front?
GK: Our way of handling HIV/AIDS was considered very controversial, at least at first. Lately we hear that what we did was the smart thing to have done at the time. The Jorge Pérez article just published by the WHO is very important (Approaches to the Management of HIV/AIDS in Cuba: Case Study, this issue). It’s a significant recognition and acknowledgement of the Cuban health care system and our approach to HIV/AIDS. Dr. Peter Piot, the UNAIDS Executive Director, has repeatedly praised the Cuban program, especially regarding prevention. In Cuba, mortality has diminished and the quality of life for people living with HIV/AIDS keeps increasing, with treatment of course. I think we’re on the right track; we’re doing very well in that respect. The total number of people infected since 1985, when the first case was detected, has been approximately 6,000. MR : That’s impressive! GK: Yes, it’s incredible. There have been 1,200 deaths. IPK is the national reference center for HIV/AIDS. People living with HIV can come whenever they wish. They can get regular attention here, whether they are sick or not. MR : I understand that the IPK is one of the institutions of the “scientific park,” which is involved in vaccine research and development – is that right? GK: All the Cuban vaccines have gone through trials here at IPK; this Institute evaluates them all. The hepatitis B vaccine, meningitis B, leptospirosis, the synthetic haemophilus influenzae vaccine…all of them. The vaccine for cholera has been a big challenge because cholera was eliminated in Cuba back in the 19th century and cholera is not endemic to Cuba. So to do the necessary evaluations, we had to induce cholera in people experimentally; we literally had to find volunteers and give them cholera because there is no animal model. Of course we first had to select the vaccine – this entails a long experimental research process: we had to find a Vibrio cholerae that was immunogenic, that was protective, but that was not toxigenic. This was done by scientists at the National Center for Scientific Research (CENIC) and also the Finlay Institute. I should be clear: we didn’t do this part here at IPK. We did the clinical trials. So once the immunogenic, non-toxigenic Vidrio cholerae was selected, the vaccine went to clinical trials. Then we administered Vidrio cholerae to both the people who had been vaccinated and the people who had not. The results were excellent (Abstracts: Construction and Characterization of a Non-proliferative El Tor Cholera Vaccine Candidate Derived from Strain 638). Cholera is an example of a disease which shouldn’t kill anyone – it responds very well to antibiotics. People die of dehydration, for lack of medical attention. It’s a disease that is directly associated with poverty. And it’s not a tropical disease either. So we did the trials and were able to demonstrate that this vaccine candidate did indeed protect against cholera in the vaccinated volunteers while all the others got sick. Now this vaccine is being produced in Cuba by CENIC and the Finlay Institute and they are ready to move on to the next phase clinical trials, which have to be carried out in a country where cholera is endemic, in Africa for example (Cuban Cholera Vaccine Headed for Clinical Trials). This is typical here in Cuba – we work collectively, all the institutions in the scientific park work together collaboratively. This institute’s role is research-based and clinical, we don’t produce vaccines, but we evaluate them and we have input during the production process. MR : Why devote so much time, energy and resources to scientific research to develop a cholera vaccine when there’s no cholera in Cuba? GK: First of all, we’re applying science. We are scientists and this is our work. It has been demonstrated for centuries now that an effective vaccine produces effective protection from infectious disease. So we produce vaccines and we have a national immunization program to protect our population. According to the World Health Organization, we have one of the best programs in the world. In the case of cholera, this will be for other Third World countries – and I’m using the term “ Third World” intentionally, rather than developing world. MR : Why? GK: Because it’s about solidarity.Cholera is a typical case, but let’s take another example: there was an outbreak of meningitis in Uruguay back when we did not have political or diplomatic relations with that country. But we sent them our vaccine free. Solidarity is a very important component of our system. Cuba has people working in more than 60 countries, for free…those countries, those people, are not charged anything. For us it’s a matter of principle. I don’t think there’s any other country in the world that does this. |
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Professor Gustavo Kourí recently welcomed MEDICC Review into his office at the Pedro Kourí Institute of Tropical Medicine (IPK; 