MEDICC Review ISSN: 1555-7960 [email protected] Cooperation with Estados Unidos

Miyar, José Limited Financial Resources Need Not Mean Poor Outcomes MEDICC Review, vol. 12, núm. 3, 2010, pp. 17-19 Medical Education Cooperation with Cuba Oakland, Estados Unidos

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Limited Financial Resources Need Not Mean Poor Health Outcomes

By José Miyar MD

Esteemed Dr Gill Samuels, Chair of the Foundation Council of the Global Forum for Health Research;

Dr José Ramón Fernández, Vice President of the Council of Ministers;

Dr José Ramón Balaguer, Minister of ;

Distinguished leaders and specialists of the Global Forum;

Representatives of the World Health Organization and the Pan American Health Organization; O Asselin © Global Forum for Health Research O Distinguished visitors accompanying us who have shared the unfolding of this very important event, dedicated to the extraordinary role of science and in- novation as essential factors for achieving health for all peoples.

This event has been characterized by rich exchanges, valu- Just a few weeks ago, we were privileged to receive in Cuba the able experiences and the worthy objectives we have in com- Director General of the World Health Organization, Dr Margaret mon, shared in an atmosphere of friendship, understanding, Chan. Her brilliant conceptualization of health services, and the respect and fraternity. For Cuba, it has been a great honor to fundamental importance and priority accorded by the WHO to receive you. as the pillar of health systems, strengthened the or- ganizational principles Cuba has applied over many years. These Once again, I would like to salute the initiative to hold this Forum are expressed in the polyclinics, family doctors, and the commu- in our country, giving us the opportunity to deepen our quest for nity itself participating in and receiving the standard and quality of better health for the world’s peoples, and to reaffi rm that work- care to which we all aspire. ing together, a better world is possible. For our part, we have opened our arms, minds and hearts to join you in pursuit of these The state of health of the world’s people—like the state of the objectives, enhanced by the diverse points of view and thoughtful planet itself—will determine the future course of humanity. opinions expressed here. Just over 30 years ago, the Declaration of Alma-Ata on primary This meeting has been held at a time of transcendental impor- established the goals of “Health for All”. But today, tance for humanity. The world is immersed in a devastating eco- humanity is far from achieving these goals, and even though nomic crisis that has shaken the entire global economy to its core. some countries have advanced in developing their health sys- tems, this is often accompanied by disparities and exclusions Unrestrained expansion of extreme amidst a world popu- from access to care. Other countries have fallen behind, among lation expected to reach 7 billion by 2012—growth almost entirely other reasons, as a consequence of the changes engendered in Third World countries—is a challenge for all those who, like by a globalized world, plagued by economic crisis and climate us meeting here today, struggle to put science and innovation to change, and by lack of political will. In these countries, public work for everyone. health systems are disappearing altogether, and human capital is rapidly being lost due to brain drain and active recruitment by Add to this the danger of the environmental crisis, its destruc- more developed countries. tive consequences, and the grave threat it represents for all the world’s peoples. Expansion of extreme forms of marginalization, Even today, most health systems in the world depend on the least devastating poverty, the food crisis, and lack of access to some- equitable form of service provision: among other things, direct fee- thing as elemental as water for billions of the Earth’s inhabitants for-service payments by patients themselves or their families in are realities derived from the abysmal difference between rich order to receive essential curative care. In low- and middle-income and poor countries; between wasteful and egocentric nations, countries, over half of all health expenditures come right from the whose consumerism has brought on the creeping destruction of pockets of the 5.6 billion people living there. This system deprives vital life processes on our planet, and the immense majority in the many families of the care they need because they simply cannot underdeveloped world for whom the most basic living conditions afford it—not even essential, inexpensive and highly effective pre- have not been ensured. vention measures such as vaccination against over ten diseases.

MEDICC Review, July 2010, Vol 12, No 3 17 Special Article

In today’s global context, even in countries with greater economic given full support to the health system’s scientifi c development, resources, the need to regain a primary care perspective is reaf- even in the worst years of the US economic blockade. fi rmed daily, not simply as an organizational concept for health services, but as a set of values and principles that orient health The impact of biotechnology on public health merits particular systems towards populations at risk, promote equitable access to refl ection in the context of this Forum, as an expression of the services, and notably improve quality and effi ciency at lower cost. triple interaction among science, industry and the health system. Biotechnology is a very young scientifi c, technological and indus- As indicated in various presentations at this event, Cuba’s health trial sector, started mainly in the United States at the end of the system rests fundamentally on the concept of bringing services 1970s. It was developed almost simultaneously in Cuba, with the closer to the population and on active public participation based fi rst center opened by President Fidel Castro in 1981. He was in essentially on primary health care. This approach has resulted in fact the one who, as early as January 1960, declared that “the vast improvements in the quality and effi ciency of the main health future of Cuba must be a future of men and women of science, of programs at household and neighborhood levels. Primary health thought”. He conceived the project, and, together with numerous care is complemented by and integrated with hospitals, institutes scientists and other experts, developed Cuban biotechnology as and other services at higher levels of care, including those rep- an advanced branch of science and technology, and as an indus- resenting the most advanced science, research and technology. try with enormous potential. His persistence, vision, confi dence and personal support facilitated notable advances in this fi eld, as Today, Cuba’s primary health care network includes 499 polyclin- in many of the country’s other essential activities. ics throughout the country and 32,289 family physicians, the ma- jority of whom are fully integrated in communities. The rest of the Today, over 10,000 scientists, engineers and technology experts system complements and supports health programs implemented work in dozens of research and production centers in Cuba’s bio- at the primary level. technology and high-end pharmaceutical industries. National re- search has enabled introduction of more than 150 products, some As noted in reports by the WHO and other international agencies, quite novel, into the health system, as well as exports to over 50 Cuban public health has clear achievements to its credit, refl ected countries, making these industries an important export sector of in the country´s main health indicators and other outcomes amply the economy. Such an achievement, resulting from the connec- described in various sessions of this event. These outcomes are tion between science, production and the economy, would be im- the result of: portant in itself. But there is something more important, especially in the context of this Forum: the distinguishing feature of Cuban First of all, the political will of the revolutionary leadership, which biotechnology is its profound connection with the health system, prioritized health and understood it as an immediately attainable resulting in a concrete impact that has improved health indicators right and not a far-off consequence of economic development. In in the whole population. fact, we see that improved population health is a prerequisite for economic development, not the reverse. Health impact is a much more Biotech fi rms in other demanding indicator than countries—mainly in Second, attainment of social justice. No effective health policy wealthier countries is possible in an unjust society, divided between a wealthy few development of a new product where some 5,000 and a great mass of marginalized poor. The standards of health companies are lo- attained in Cuba—on par and sometimes better than those in cated—develop products, and some of these make profi ts from highly developed nations, despite the country’s low GDP per their sale. But it is not clear that they have made an impact on capita—eloquently demonstrate that health is more sensitive to population health indicators. Health impact is a much more de- equity than to wealth. If what one has is distributed well, then manding indicator than development of a new product: it requires health indicators improve. that products successfully pass rigorous trials leading to registra- tion, that industrial scale-up of their manufacture is possible; and Third, the concept of “health coverage”. All health services must what’s more, that there is a health system capable of putting these be available to everyone. It is a scientifi cally proven fact that products within reach of all who need them and of inserting them broad coverage is the main factor determining impact of any in “technological health packages” in combination with other inter- health intervention. ventions to solve specifi c health problems.

Fourth, the priority afforded to developing human resources for The fact that Cuba has a highly effective recombinant hepatitis B health, which has given us the highest ratio of health profession- vaccine is an achievement. But a much greater achievement is als per capita of any country, and made possible extensive inter- that the incidence of hepatitis B has reached zero among children national solidarity in the health sector. and has dropped drastically in adults. This illness, wreaking havoc worldwide, is on its way to eradication in Cuba. Another key aspect of Cuban public health outcomes has been their underpinning in science. Beginning in the 1960s with accel- The fact that Cuban biotechnology produces antigens for eight erated assimilation of the world’s best medical and health knowl- vaccines used in a mass childhood vaccination program against edge, this scientifi c foundation was later extended to the estab- 12 diseases is an achievement. But a greater achievement is the lishment of the Ministry of Public Health’s research institutes, then nearly 100% coverage of Cuban children—free of charge—by to development of medical specialties, and fi nally in the 1980s, these vaccines, including those for meningococcal meningitis and to creation of the Western Havana Scientifi c Pole and Cuba’s Haemophilus infl uenzae type b (Hib), for which Cuba’s vaccine biotechnology industry. The revolutionary leadership has always is the fi rst in the world using a synthetic antigen. As a result, in-

18 MEDICC Review, July 2010, Vol 12, No 3 Special Article cidence and mortality from these diseases are almost zero, and both to serve everyone. Moreover, the two strategies should infant mortality has decreased to 4.7 per 1000 live births in 2008. mutually strengthen each other, resulting in a health system Vaccination and a host of comprehensive health programs, along that is high-tech and at the same time offers ample coverage with additional measures adopted by the health system, have al- based on strong primary care. That is the secret. This also re- ready led to elimination of 5 diseases in Cuba and control of a quires building national capacity for scientifi c research, produc- number of others. tion and application.

Another achievement of Cuban biotechnology is national produc- Is this diffi cult? Without a doubt. It takes a lot of effort and commit- tion of recombinant erythropoietin; but a greater achievement is ment, but not so much money. Limited fi nancial resources do not that this high-cost product is available to 100% of patients with condemn a country to poor health if the resources are distributed chronic kidney disease and other serious diseases requiring it. and used well, and if we train health and science workers commit- ted to their mission and their people. If there is one contribution Production of immunodiagnostic systems, assisted by computers Cuba can make in this fi eld it is to prove that it can be done. and reagents, is also an achievement of Cuban science. But a greater achievement is that 100% of pregnant women are tested I believe that an essential result of this event should be to suggest with modern prenatal diagnostic methods capable of screening to the WHO that a fundamental goal for the international commu- for over 20 conditions, and that transmission of viral diseases nity should be to support those countries whose health services through blood transfusions has been eliminated. have been devastated and that have lost personnel by ensuring them the minimum resources necessary to attain the goals pro- And we could cite many other examples. posed here.

The concept is that for the Cuban biotech industry, population Cuba, a poor and underdeveloped country, has borne the brunt health and health programs, science must achieve products, but of nearly half a century of a brutal economic blockade. During the what comes after is not simply a “commercial operation”, but rath- same 50 years, in a world plagued by exploitation, inequality, pov- er a commitment to introduce the new technology into the health erty and injustice, it has demonstrated that the moral and ethical system with broad coverage and to evaluate its impact on health value of solidarity dignifi es and elevates those who practice it. Such indicators. solidarity is at the heart of our internationalism, guiding our com- mitment to cooperation with dozens of countries in the Third World Concrete examples are the links between the Finlay Institute, through programs that reach and benefi t millions of poor people, which produces our vaccines, and other biotech centers with the representing the highest degree of humanism a country can offer Ministry of Public Health’s vaccination programs; the link between to this world. the Immunoassay Center and the national Maternal-Child Health Program; and between the Molecular Immunology Center and Thank you. national programs for control of cancer and other devastating noncommunicable chronic diseases, through application of their achievements in the primary health care system. Editors’ Note: Remarks delivered by Dr José Miyar, Cuban Min- What we are addressing is the false dichotomy between high- ister of Science, Technology & the Environment, at the plenary tech health care (often reserved for elites) and low-tech prima- session of Forum 2009: Innovating for the Health of All, November ry health care (for the broad population). The key is developing 20, 2009, Havana, Cuba.

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