The following interview with Dr. JosĂ© Luis Di Fabio, the Pan American Health Organization and World Health Organization representative in Cuba,Â was published in the October issue of MEDICC Review. We appreciate MEDICC Review’s permission to republish the article.
By Gail Reed
He sips mate, the bitter brew of his native Uruguay as he conversesÂ at PAHOâ€™s offi ces in Havana. Yet, he already feels atÂ home here, says Dr. Di Fabio, who took up his post in July ofÂ 2011. This is not surprising, since his connection to CubanÂ health care and research predates his arrival by two decades.Â In 1992â€“93, he worked on the Americasâ€™ vaccine system (SIREVA)Â for PAHO and became involved in monitoring cooperationÂ in vaccine regulatory issues, quality and production. From thatÂ period emerged one of Latin Americaâ€™s great achievements:Â Vicente VĂ©rez Bencomoâ€™s development at the University ofÂ Havana of the worldâ€™s firstÂ Haemophilus influenzae type b (Hib)Â synthetic-antigen vaccine. Dr. Di Fabio came to Cuba often toÂ follow up on the vaccineâ€™s regulatory process, production, andÂ quality control for PAHO.Â Later, he continued working on access to vaccine technologyÂ at PAHO headquarters in Washington, DC. Itâ€™s a journey thatÂ has taken him not only far from home, but also from his professionalÂ beginnings in Vancouver, Canada, as a PhD in organicÂ chemistry. But itâ€™s Dr. Di Fabioâ€™s â€śchemistryâ€ť with Cuba that isÂ the subject of our conversation, his openness incongruent withÂ the stiff antique furniture in his upstairs PAHO quarters â€” whichÂ nevertheless offer one of the best tree-top views of the CubanÂ capital.
MEDICC Review: Many say the Cuban health system is atÂ a crossroads today. How do you perceive its achievements,Â the challenges ahead?
JosĂ© Luis Di Fabio: When it comes to health, Cuba is privilegedÂ in many ways. First, for five decades the country has had a universalÂ public health system backed by political decisions that haveÂ made its development a priority. Other countries are still trying toÂ achieve this. Cubaâ€™s challenge is different: itâ€™s how to maintainÂ and sustain that system by adopting new fi nancing mechanisms,Â optimizing resources, and managing technologies efficiently. ThisÂ means structural redesign of some parts of the system.
Second, Cuba is also privileged with its high doctor-patient ratioÂ and its guarantee of access to care built on a strong primaryÂ health care network, in which family doctor-and-nurse offices andÂ polyclinics serve all residents in a local geographic area.Â The challenge now is to maintain quality of care while reducingÂ dependency on technology at some levels. To accomplish this,Â the Cubans are proposing more reliance on physiciansâ€™ clinicalÂ skills and more rational use of technology, especially in primaryÂ care.
For example, equipping the countryâ€™s some 450 communityÂ polyclinics with the same technology is costly, and doesnâ€™t takeÂ into account that each facility serves a different size populationÂ with different epidemiological characteristics. So â€ścookie-cutterâ€ťÂ technology distribution is inefficient and, recognizing this, healthÂ authorities are moving to optimize use of equipment, relocating itÂ to where it makes the most sense.Â Of course, the problem is that once people get used to havingÂ the technology at their community clinic, itâ€™s difficult to convinceÂ them that their quality of care wonâ€™t suffer when itâ€™s moved. So thisÂ becomes a concern.
Third, human resources: the fact that training of health professionalsÂ is under the aegis of the Ministry of Public Health is anotherÂ advantage. This means you can better align training with theÂ countryâ€™s needs, including locating schools in each province toÂ ensure more equitable distribution of health professionals. ThisÂ isnâ€™t so in other countries, where such questions take up considerableÂ negotiating time among ministries and other actors.
And finally, this health system is not about medicine as a business.Â Unfortunately, in many other nations, people think of medicineÂ as a career to make money. Here, we still see the altruism ofÂ medicine as service. That isnâ€™t to say Cuban health professionalsÂ are adequately paid â€” increasing salaries is recognized as oneÂ of the big challenges, even at the highest levels of government.Â They have to find the resources.
Looking ahead, I think Cuba faces other important challenges â€”Â including an aging population and the services it will require, and theÂ greater capacity needed to plan for this demographic shift. This alsoÂ means taking full advantage of preventive strategies at hand today.
MEDICC Review: Can you exemplify how Cuba is â€śpluggedÂ inâ€ť to the PAHO system regionally?
JosĂ© Luis Di Fabio: One way is the designation of 10 PAHO/WHO Collaboration Centers in Cuba â€” contributing expertise andÂ experience to advance our regional and global agendas for healthÂ and health equity.Â The Latin American Center for Disaster Medicine (CLAMED), forÂ example, draws from decades of Cubaâ€™s own experience in disasterÂ mitigation and management, as well as that of Cuban medicalÂ teamsâ€™ cooperation abroad. CLAMED trains the Henry Reeve Contingent,Â 10,000 specialized professionals prepared and equippedÂ as rapid responders to epidemics, hurricanes, earthquakes, toxicÂ spills and the like. The Contingentâ€™s record, with its accumulatedÂ capacity and knowledge in places such as Pakistan and Haiti, isÂ impressive; itâ€™s also the result of having a single public health systemÂ that can quickly deploy human as well as material resources.
On another front, CLAMED has been involved from the beginningÂ in PAHOâ€™s Safe Hospital initiative, designed to keep hospitals andÂ other health facilities operational during and after disaster strikes.Â The effort involves architects, engineers and others besidesÂ health professionals; the norms for evaluating the safety of theseÂ health facilities came originally from CLAMED. After several bigÂ hurricanes hit Cuba in 2008, we held regional workshops, andÂ from these, a guide to mental health in disaster situations alsoÂ emerged, with important Cuban participation.
One major problem remains: Cubansâ€™ arenâ€™t publishing enough,Â so their experiences are not accessible to the rest of the world.Â And they have a lot to offer: the article in MEDICC Review presentingÂ results from 15 years monitoring vaccine-related adverseÂ events in Cuban children provides information we canâ€™t findÂ anywhere else in Latin America or the Caribbean [see MEDICCÂ Review, January 2012].
Yet, it took a long time coming. Part of the problem is that muchÂ of the international literature is published in English, which is anÂ obstacle encountered by researchers in many other countries ofÂ the Americas as well.
MEDICC Review: How does PAHO work in Cuba itself?
JosĂ© Luis Di Fabio: We have a country cooperation strategyÂ through 2015, based on a set of 10 priorities worked out withÂ the Ministry of Public Health. These are consistent with the principlesÂ and priorities of the national health system, and also withÂ the WHOâ€™s medium-term strategic program and the MillenniumÂ Development Goals â€” our aim is to align all these to make moreÂ impact where we can. Much of what we do concerns efforts toÂ strengthen the efficiency, quality and sustainability of Cubaâ€™sÂ health system, particularly in primary health care.
In 2010â€“2011, nearly $3.4 millionÂ was assigned from the central PAHOÂ budget to technical cooperation withÂ Cuba, and another $3.3 millionÂ was raised through PAHO from otherÂ sources.
One example of PAHOâ€™s work here isÂ our decentralized technical cooperationÂ with local governments, related toÂ issues ranging from maternal-childÂ health to cancer and other chronic diseases,Â domestic violence, communityÂ mental health, protection of children inÂ disasters, and healthy aging.
MEDICC Review: You mention theÂ Millennium Development Goals, aÂ strategy emphasizing intersectoralÂ approaches. How do these comeÂ into play in PAHOâ€™s cooperation withÂ Cuba?
JosĂ© Luis Di Fabio: IntersectoralÂ approaches are vital to health, and thusÂ to all our PAHO projects, which aim toÂ complement other efforts at local development,Â including those of the rest ofÂ the UN system.Â Safe drinking water, social and economicÂ integration, education, exercise,Â food security, traffic safety â€” none of these can beÂ addressed by the health sector alone.Â We have a project just getting off the ground inÂ Cienfuegos looking at mortality from cancer â€”Â now the number one cause of death in thatÂ province. Through the comprehensive healthÂ services network (headed by the provincial hospital,Â another WHO/PAHO Collaborating Center),Â new ways to approach this problem areÂ being designed, relying on data from primaryÂ health care providers and other levels of theÂ health system.Â The different kinds of cancers will be mapped,Â and improvements devised â€” especially in preventionÂ and early detection strategies â€” toÂ address these where they are most prevalent.
Some domestically-developed tools are alsoÂ available, such as the national ImmunoassayÂ Centerâ€™s test for human fecal blood for earlyÂ detection of colon cancer.
But no matter which cancer you are confronting,Â prevention is complicated and needs intersectoralÂ cooperation. Just look at lung cancer in Cuba: smoking isÂ banned in public buildings, but if this is not enforced, the healthÂ sector canâ€™t do its job. If diet, alcohol consumption and smokingÂ are not addressed urgently, we will see cancer rates rise;Â if stress is not reduced through regular exercise, more risk isÂ added to the picture.
MEDICC Review: You mentioned the Immunoassay Center,Â part of Cubaâ€™s â€śscientific pole,â€ť working in biotech andÂ other R&D. How do you view the countryâ€™s approach toÂ biotech?
JosĂ© Luis Di Fabio: The U.S. embargo and other economic constraintsÂ have forced innovation to meet the demands and fulfillÂ the commitment of Cubaâ€™s universal health care system. OneÂ way is through products developed by biotech R&D. AlthoughÂ export revenues are derived, the main purpose is not to strike itÂ rich, but rather to make these new vaccines and other medicationsÂ available to resolve pressing health problems in Cuba andÂ elsewhere.
The closed loop approach has worked here, in which biotechÂ institutions cooperate from initial research, through development,Â trials, national use and marketing. This contribution has alsoÂ benefi ted South-South cooperation, with Brazil and Cuba offeringÂ a case in point. Their cooperation on production of millionsÂ of doses of meningococcal vaccine A+C for Africaâ€™s â€śmeningitisÂ beltâ€ť is a model of joint venture and technology transfer: CubaÂ manufactured the polysaccharide components and Brazil did theÂ formulation and completed the fi nal product, resulting in a vaccineÂ prequalifi ed by the WHO.
More recently, an important agreement was signed betweenÂ Brazil and Cuba for technology transfer of many biotech medicalÂ products developed in Cuba. And of course, Cuba has alsoÂ transferred technology to countries such as India, China andÂ South Africa.
MEDICC Review: Is PAHO involved in Cubaâ€™s global healthÂ cooperation?
JosĂ© Luis Di Fabio: Some 40,000 Cuban health professionalsÂ are posted abroad in places where public health services wereÂ few or non-existent. These teams encounter realities, not justÂ diseases, which are very different from what they see in Cuba.Â These include different cultures and traditions. In Bolivia, forÂ example, women are accustomed to vertical birthing and manyÂ indigenous people donâ€™t want to be hospitalized for fear they willÂ be blamed for dirtying the sheets, so maligned have they beenÂ for centuries.
So, weâ€™ve begun working with the Cuban Public Health Ministryâ€™sÂ Medical Collaboration Unit and others to provide more backgroundÂ on the history and cultures of the countries where CubanÂ health professionals serve, to ensure they have the best preparationÂ possible before they go.
MEDICC Review: The Latin American Medical School (ELAM)Â is probably the worldâ€™s largest medical school with an explicitÂ social mission. What is PAHOâ€™s relationship to the school?
JosĂ© Luis Di Fabio: ELAM enrolls 20,000 students from over 100Â countries, and their graduates are doubtless having an impact.Â This program is also facing challenges in terms of inserting theseÂ new MDs into medical practice in their home countries: there isÂ disinformation that foments ignorance. And there is resistanceÂ from some in the medical profession itself, particularly amongÂ specialists who were trained so differently. They donâ€™t understandÂ these ELAM doctors who were trained mainly in communityÂ settings and health facilities â€” something you donâ€™t see in manyÂ countries.
So, they criticize ELAM graduates for many things, among themÂ not receiving training relevant to local needs. In several places,Â Cuban medical educators have introduced an interesting innovation that addresses such concerns, in which students spendÂ their last one or two years under the tutelage of Cuban professorsÂ serving in the studentsâ€™ own countries. This is one measureÂ that should have a positive effect and on recognition of the ELAMÂ degree by more countriesâ€™ accreditation bodies.
Interestingly, such obstacles arenâ€™t faced by the over 190 U.S.Â ELAM students and graduates, who have to pass the sameÂ boards as those who went to school in the United States itself; orÂ in European countries such as Spain, where the ELAM degree isÂ recognized.Â PAHO signs every graduateâ€™s MD degree, attesting to its validity.Â And we would like to do more to support ELAM in its graduate outcomeÂ and impact studies through its human resources observatoryÂ program and to assist in debunking some of the myths aboutÂ its curriculum. Our reasoning is clear: the world needs doctors forÂ primary health care, doctors who come from, and are willing toÂ practice in, distressed communities and rural areas, and who areÂ well acquainted with their own culture and respect others.
MEDICC Review: What would you like to accomplish duringÂ your tenure here as PAHO/WHO representative?
JosĂ© Luis Di Fabio: Most of all, to help share the lessons from aÂ 50-year old universal health care system that is unique in the world.Â I would also like to enhance the impact of Cuban biotech andÂ South-South cooperation through regional vaccine and antiretroviralÂ production networks and through strengthening of theÂ regionâ€™s regulatory framework. This includes involving the workÂ done by Cubaâ€™s National Drugs Quality Control Center and itsÂ National Clinical Trials Coordinating Center â€” the latter responsibleÂ for the first accredited clinical trials registry in the region.
Finally, I would like to build greater confi dence in Cuba itself inÂ PAHOâ€™s willingness and capacity to cooperate effectively with theÂ Cuban health systemâ€™s efforts to enhance sustainability, quality ofÂ services, and its global contribution to health equity. Such confidence must underpin everything we do: we are here to support,Â to help, to accompany.
PAHO/WHO Collaborating Centers in Cuba, 2012
Collaborating Center for Integrated Medical Care Services in Diabetes
Collaborating Center for Research in Human Reproduction
National Hygiene, Epidemiology and Microbiology Institute:
Collaborating Center for Health in Housing
Pedro KourĂ Tropical Medicine Institute:
Collaborating Center for Tuberculosis and other Mycobacteria
Collaborating Center for the Study and Control of Dengue
National Medical Genetics Center:
Collaborating Center for Development of Genetic Approaches for Health Promotion
National Medical Sciences Information Center:
Collaborating Center for Development of the Virtual Health Library
Occupational Health Institute:
Collaborating Center for Occupational Health
Research Center in Longevity, Aging and Health (CITED):
Collaborating Center in Public Health and Aging
Dr Gustavo AldereguĂa Lima University Hospital:
Collaborating Center in Hospital Organization, Management and Quality