- Email: [email protected]
United States–Cuba Research Collaborations: Opening Bridges for Gastroenterology
Accepted Manuscript US-Cuba research collaborations: opening bridges for gastroenterology Maria T. Abreu, MD, Oriana M. Damas, MD, Felipe Neri Piñol Jiménez, MD, MS, PhD, Roberto Cañete, MD, MS, PhD
PII: DOI: Reference:
S0016-5085(17)30294-9 10.1053/j.gastro.2017.03.011 YGAST 61043
To appear in:
Gastroenterology
Please cite this article as: Abreu MT, Damas OM, Piñol Jiménez FN, Cañete R, US-Cuba research collaborations: opening bridges for gastroenterology, Gastroenterology (2017), doi: 10.1053/ j.gastro.2017.03.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
US-Cuba research collaborations: opening bridges for gastroenterology
RI PT
The American policy towards Cuba is rapidly evolving. Given its proximity to the US, it is natural to imagine collaborations between our two countries. The Cuban health care system and biotechnology industry are quite advanced. In the current commentary, we describe the training of Cuban gastroenterologists and the structure of gastrointestinal care in Cuba. The aim of this commentary is to create awareness of the richness of the intellectual resources of our colleagues in Cuba and the potential for future collaborations.
M AN U
SC
The restrictions on travel to Cuba have until recently limited the contact most Americans have had with the island and its people. Yet many Americans are fascinated by its neighbor only 90 miles from Florida In December of 2014, President Obama liberalized travel to Cuba (https://www.treasury.gov/resource-center/sanctions/Programs/Documents/cuba _faqs_new.pdf (see number 5)) with cultural, educational, and academic exchange among the approved reasons Americans may travel to Cuba.
TE D
The Cuban healthcare system has been recognized for its unequivocal successes including its emphasis on primary care and prevention[1, 2]. 95% of pregnant women receive prenatal care, which results in an infant mortality rate of less than 5 per 1000 births[2]. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 77 and 81 years of age in men and women, respectively, is virtually identical to that in the United States[3]. In addition to caring for the Cuban population, Cuban physicians and allied health professionals perform medical work in several countries including Venezuela, Bolivia and, Brazil where there is a dearth of medical care in rural areas. Thus, at any given time there is a significant number of Cuban doctors practicing abroad[4].
AC C
EP
Cuban biotechnology has developed vaccines for dengue, a recombinant human epidermal growth factor for diabetic foot ulcers, and a vaccine for non-small cell lung cancer—to name some of the most prominent accomplishments[5]. In June 2016, the U.S. Department of Health and Human Services (HHS) and Cuba’s Ministry of Public Health signed an agreement to foster cooperation between the two countries in public health and medical research [6]. This historic step should lead to greater opportunities for US-Cuba collaboration in healthcare. In this commentary, we will describe the Cuban medical system with special attention to opportunities for collaboration and research in gastroenterology and hepatology. Training of physicians and scientists High school graduates with the strongest academic performances are accepted into a sixyear medical school. There has been an increase in the number of medical schools and thus medical graduates in the country. Cuba is divided into 15 provinces and has 13 medical schools along the island, with varying numbers of students[7]. The medical schools function autonomously from one another and are accredited by the Ministry of Public Health, similar to our AAMC. Cuban medical students do not take national level exams analogous to the US Medical License Examinations (USMLEs), only exams at their
ACCEPTED MANUSCRIPT
individual universities. There are exams throughout medical school. The last three years of medical school consist of rotations in the main medical specialties (medicine, pediatrics, surgery, gynecology) with an exam at the end of each educational module. After passing all the medical exams, they are allowed to practice medicine as general medicine physicians and their diploma is awarded by the medical school and the Ministry of Public Health.
M AN U
SC
RI PT
Gastroenterology training generally follows medical school. Although there is no formal match process, acceptance into a gastroenterology program is competitive and candidates typically must have performed well in medical school to be considered. The graduates that go in to gastroenterology generally stay in the province where they have attended medical school. Gastroenterology fellowship is a total of three years, a year of internal medicine and two years of GI. The internal medicine year is embedded at the beginning of the three-year training program and consists of the essential aspects of internal medicine necessary for a gastroenterologist. In certain cases, a medical student may have chosen to perform a threeyear internal medicine residency and later applied for a gastroenterology fellowship position; in which case, they would not be required to do a full year of internal medicine first. General medicine physicians compete for a limited number of positions and are generally accepted into a gastroenterology training program if there is a need in their province for more GI specialists. The number of gastroenterology training spots at a specific hospital is determined annually based on the needs of the province.
AC C
EP
TE D
Training in gastroenterology consists of lectures, workshops, conferences, and clinical work with an emphasis on the latest scientific advances. After every educational module, usually every six months, the fellow must demonstrate clinical and procedural proficiency in gastroenterology and hepatology to progress in their training. Requirements also include completion of a thesis during training. The quality of individual thesis projects is often of publication quality but because of language and cost, these generally go unpublished or appear only in local or less visible medical journals. At the end of the three years, trainees have to pass a week-long examination in which they evaluate GI patients, perform procedures (EGD, colonoscopy, liver biopsies, laparoscopy), take a written exam, defend their thesis, and answer oral exam questions before a tribunal of gastroenterology professors. For the academic GI programs in Havana, the exam takes place at the Institute of Gastroenterology but for most other provinces, it occurs at their local institution. Once all the requirements are complete, the diploma in gastroenterology is awarded by the Ministry of Public Health. Cuban trainees do not have to pay for any part of their education or their training. In Latin America, however, fellows pay to do a GI fellowship. Occasionally, medical graduates from Latin America come to Cuba to do their gastroenterology training both because of the high quality of the programs as well as the lower cost of training [8]. The faculty that train gastroenterology fellows, as with all physicians in Cuba, are paid a salary by the state. If they are involved in training fellows or teaching medical students, they are paid a supplement based on their academic rank, i.e. instructor, assistant, associate, senior level professor. For faculty to become promoted, they must teach, do research, and/or publish. Medical doctors can become certified “researchers” by taking exams and presenting a dissertation on a topic to become promoted. Faculty may also obtain a PhD from the
ACCEPTED MANUSCRIPT
Ministry of Higher Education based on their accomplishments and their compendium of publications. In this way, they can advance from the equivalent of assistant or junior professors to senior or full professors.
SC
RI PT
Gastroenterology fellows who wish to pursue a PhD degree generally spend an additional 5 years to complete a project. This may be the same project that they did for their gastroenterology thesis or a new one. Their PhD degree is awarded by the Ministry of Higher Education and, like in the US, is contingent on the productivity of the student and may take more or less time to complete. With respect to conventional PhD training (i.e. non-MDs), students first complete five years of university and then apply to PhD programs. Acceptance generally depends on a high GPA. Ph.D. programs are five years and students have an opportunity to rotate through different scientific institutes to choose a mentor and a laboratory. Their graduation thesis is presented to a committee to obtain their degree. It is not infrequent for master’s students and PhDs to receive international grants to perform post-doctoral training abroad.
M AN U
The healthcare system with a focus on gastroenterology
TE D
Each of Cuba’s 15 provinces has a main teaching hospital that offers secondary level care to the people of the province. Most, but not all, of these provincial hospitals have the ability to perform upper and lower endoscopy. There is also a system of peripheral outpatient clinics and smaller hospitals that often have a gastroenterologist, typically with the ability to perform upper endoscopy but generally not colonoscopy. Although the local gastroenterologist can resolve most common issues, she/he has the ability to easily refer patients to a higher level of care if necessary. Nevertheless, the provincial hospitals offer the opportunity to capture data as it relates to gastroenterology because for most complex diseases, such as IBD, most patients would be referred to the provincial hospital for diagnosis and management.
AC C
EP
The medical record of a patient is on paper but is extremely detailed. The record stays with the local primary doctor and when a patient seeks a consultation with a specialist, the evaluation of the specialist is added to the file. In the special case of gastroenterology, several hospitals benefit from an application called “ProGastro” developed by a young Cuban gastroenterologist interested in informatics [9]. ProGastro is a simpler version of our Provation. The physician or assistant enters the type of procedure, the findings, the intervention, whether biopsies were obtained, and eventually the final pathology reading. The application allows for easy searching of the database by diagnosis (picked from a pull down menu) or a text search, which may facilitate research projects. The application is used by several of the larger gastroenterology departments, but not all. On the other hand, the hospitals that have the application tend to serve as referral centers for a large catchment area and may provide an opportunity for collaborative research. In many hospitals, however, the endoscopy data remains part of the patient’s paper chart. Tertiary level care in gastroenterology and most other areas of medicine is available in Havana at several institutions. Cuban gastroenterologists at elite institutions have obtained advanced endoscopic training in Japan, Canada, Spain, and Germany. Depending on the
ACCEPTED MANUSCRIPT
RI PT
need of the patient, the provincial gastroenterologist will refer the patient to hospitals that offer specific services. The Institute of Gastroenterology in Havana has motility equipment, capsule endoscopy, and performs hepatitis B and C viral load testing. The National Center for Minimally Invasive Surgery (Centro Nacional de Cirugía de Minimo Acceso) offers advanced endoscopic techniques including endoscopic ultrasound, endoscopic mucosal resections, and capsule endoscopy. Many of its specialists have trained abroad and offer courses on advanced endoscopic techniques to colleagues in neighboring provinces. Finally, the Hermanos Ameijeiras Hospital is a 1000 bed hospital with tertiary care in most specialties including gastroenterology and liver transplantation.
The biotechnology industry in Cuba
M AN U
SC
Recently, the Cuban public health system placed an emphasis on screening for colorectal cancer. This has been made possible by the development in Cuba of their own fecal immunohistochemical test termed SUMASOHF (Sistema Ultra Micro Analitico para la deteccion de Sangre Oculta en Feces Humanas)[10, 11]. Primary care doctors perform the occult blood test on all patients over 50. The challenge remains providing colonoscopies to patients with positive tests. At present, most patients present with more advanced adenomas or cancers. The country has also provided hepatitis B vaccination trough their primary care network since 1995.
EP
TE D
As alluded to previously, Cuba has a vibrant biotech industry that has developed various vaccines and other technologies. Some of the best known research institutes in Cuba include the Center for Genetic Engineering and Biotechnology (Centro de Ingeniería Genética y Biotecnología (CIGB)), the National Center for Scientific Investigations (Centro Nacional de Investigaciones Científicas (CNIC)), the Center for Immunological Studies (Centro de Inmunoensayo (CIE)), and the Institute of Tropical Medicine ‘Pedro Kouri’ (Instituto de Medicina Tropical Pedro Kouri (IPK)). In addition to a FIT test for occult blood, they have developed a hepatitis B vaccine[12]. Unfortunately, the cost of publishing papers is frequently a barrier to dissemination of their work. In spite of these challenges, several recent biotech developments like Heberprot-P, epidermal growth factor, for diabetic foot ulcers and CIMAvax for lung cancer have gotten the attention of US academia and pharma and are currently in clinical trials in the US.
AC C
Opportunities for research in Cuba There are many wonderful opportunities to partner with Cuba to perform collaborative research. The physicians and scientists are highly trained. The finite number of hospitals offering diagnostic and therapeutic options means that it is possible to obtain prevalence data for specific gastrointestinal conditions. The same is true in hepatology wherein serum from patients with hepatitis B or C is sent to one institute for testing. All institutions have a uniform process for ethics board approval. The perception from Cuban doctors is that their patients are willing to participate in clinical studies if it will help increase knowledge. Of course the important limitation of Cuban healthcare is limited financial resources; thereby restricting access to equipment and medications for patients. Cuban patients have generally not been exposed to expensive medical interventions. In the US it has become difficult to recruit IBD or hepatitis patients that are naïve to biologic medications. By
ACCEPTED MANUSCRIPT
SC
M AN U
Maria T. Abreu, MD Director, Crohn's & Colitis Center Martin Kalser Chair in Gastroenterology Professor of Medicine Professor of Microbiology and Immunology Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine
RI PT
contrast, Cuban patients have generally not received any expensive medical treatments and may therefore benefit from the opportunity to participate in clinical trials. Finally, as exchange with Cuba becomes more commonplace, we can imagine scientific exchange and shared post-doctoral training programs. It is our hope that medicine and science will lead the charge of normalized relations with our Cuban colleagues.
Oriana M. Damas, MD Assistant Professor of Medicine, Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine
TE D
Felipe Neri Piñol Jiménez, MD, MS, PhD Professor and Senior Investigator, University of Havana School of Medicine Master in Infectious Diseases Honorary Member of the Cuban Society of Gastroenterology International Member, American Society of Gastrointestinal Endoscopy
1.
2. 3. 4.
AC C
EP
Roberto Cañete, MD, MS, PhD Director of Matanzas’ Council of Scientific Health Societies Full Professor and Senior Researcher University of Medical Sciences and Center of Hygiene, Epidemiology, and Microbiology. Matanzas, Cuba
Khemlani, A., World Health Organization, Cuba: WHO Praises Efforts and Contributions to Health Education and Prevention. Agencia Cubana de noticias- Latin Post, 2014. Loewenberg, S., Cuba's focus on preventive medicine pays off. Lancet, 2016. 387(10016): p. 327-9. Sosa, O.A., Crece esperanza de vida geriatrica in Cuba. Cubadebate, 2014. Frist, B., Cuba's Most Valuable Export: Its Healthcare Expertise. http://www.forbes.com/sites/billfrist/2015/06/08/cubas-most-valuable-exportits-healthcare-expertise/#1507e133325c, 2015.
ACCEPTED MANUSCRIPT
11. 12.
RI PT
SC
10.
M AN U
8. 9.
TE D
7.
EP
6.
Cobian, C.O., et al., P2.32: Survival Assessment of Non-Small Cell Lung Neoplasia Patients in Advanced Stage Treated With the CIMAvax-EGF Vaccine: Track: Immunotherapy. J Thorac Oncol, 2016. 11(10s): p. S235-s236. Keck, C.W., The United States and Cuba - Turning Enemies into Partners for Health. N Engl J Med, 2016. 375(16): p. 1507-1509. Balbosa, N., Study medicine in Cuba, an option for young people in the world. Granma Newspaper https://translate.google.com/translate?hl=en&sl=es&u=http://www.granma.cu/cu ba/2016-04-08/estudiar-medicina-en-cuba-una-opcion-para-jovenes-del-mundo08-04-2016-16-04-26&prev=search, 2016. García, N.V., La escuela más avanzada del mundo. Juventud Rebelde, 2014. Villa-Jiménez, O.M., ProGastro System http://www.microsofttranslator.com/BV.aspx?ref=IE8Activity&a=http%3A%2F%2 Fwww.ige.sld.cu%2Farchivos%2Fpages%2Fprogastro.html, 2015. Cuba Develops Quick Colon Cancer Test. http://www.cadenagramonte.cu/english/show/articles/12147:cuba-developsquick-colon-cancer-test, 2012. Gonzalez, R.S., Cancer Screening. Global Debate and Cuban Experience. MEDICC, 2014. 16(3-4). Jain, A., et al., A multicentric evaluation of recombinant DNA hepatitis B vaccine of Cuban origin. Trop Gastroenterol, 2000. 21(1): p. 14-7.
AC C
5.
PII: DOI: Reference:
S0016-5085(17)30294-9 10.1053/j.gastro.2017.03.011 YGAST 61043
To appear in:
Gastroenterology
Please cite this article as: Abreu MT, Damas OM, Piñol Jiménez FN, Cañete R, US-Cuba research collaborations: opening bridges for gastroenterology, Gastroenterology (2017), doi: 10.1053/ j.gastro.2017.03.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
US-Cuba research collaborations: opening bridges for gastroenterology
RI PT
The American policy towards Cuba is rapidly evolving. Given its proximity to the US, it is natural to imagine collaborations between our two countries. The Cuban health care system and biotechnology industry are quite advanced. In the current commentary, we describe the training of Cuban gastroenterologists and the structure of gastrointestinal care in Cuba. The aim of this commentary is to create awareness of the richness of the intellectual resources of our colleagues in Cuba and the potential for future collaborations.
M AN U
SC
The restrictions on travel to Cuba have until recently limited the contact most Americans have had with the island and its people. Yet many Americans are fascinated by its neighbor only 90 miles from Florida In December of 2014, President Obama liberalized travel to Cuba (https://www.treasury.gov/resource-center/sanctions/Programs/Documents/cuba _faqs_new.pdf (see number 5)) with cultural, educational, and academic exchange among the approved reasons Americans may travel to Cuba.
TE D
The Cuban healthcare system has been recognized for its unequivocal successes including its emphasis on primary care and prevention[1, 2]. 95% of pregnant women receive prenatal care, which results in an infant mortality rate of less than 5 per 1000 births[2]. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 77 and 81 years of age in men and women, respectively, is virtually identical to that in the United States[3]. In addition to caring for the Cuban population, Cuban physicians and allied health professionals perform medical work in several countries including Venezuela, Bolivia and, Brazil where there is a dearth of medical care in rural areas. Thus, at any given time there is a significant number of Cuban doctors practicing abroad[4].
AC C
EP
Cuban biotechnology has developed vaccines for dengue, a recombinant human epidermal growth factor for diabetic foot ulcers, and a vaccine for non-small cell lung cancer—to name some of the most prominent accomplishments[5]. In June 2016, the U.S. Department of Health and Human Services (HHS) and Cuba’s Ministry of Public Health signed an agreement to foster cooperation between the two countries in public health and medical research [6]. This historic step should lead to greater opportunities for US-Cuba collaboration in healthcare. In this commentary, we will describe the Cuban medical system with special attention to opportunities for collaboration and research in gastroenterology and hepatology. Training of physicians and scientists High school graduates with the strongest academic performances are accepted into a sixyear medical school. There has been an increase in the number of medical schools and thus medical graduates in the country. Cuba is divided into 15 provinces and has 13 medical schools along the island, with varying numbers of students[7]. The medical schools function autonomously from one another and are accredited by the Ministry of Public Health, similar to our AAMC. Cuban medical students do not take national level exams analogous to the US Medical License Examinations (USMLEs), only exams at their
ACCEPTED MANUSCRIPT
individual universities. There are exams throughout medical school. The last three years of medical school consist of rotations in the main medical specialties (medicine, pediatrics, surgery, gynecology) with an exam at the end of each educational module. After passing all the medical exams, they are allowed to practice medicine as general medicine physicians and their diploma is awarded by the medical school and the Ministry of Public Health.
M AN U
SC
RI PT
Gastroenterology training generally follows medical school. Although there is no formal match process, acceptance into a gastroenterology program is competitive and candidates typically must have performed well in medical school to be considered. The graduates that go in to gastroenterology generally stay in the province where they have attended medical school. Gastroenterology fellowship is a total of three years, a year of internal medicine and two years of GI. The internal medicine year is embedded at the beginning of the three-year training program and consists of the essential aspects of internal medicine necessary for a gastroenterologist. In certain cases, a medical student may have chosen to perform a threeyear internal medicine residency and later applied for a gastroenterology fellowship position; in which case, they would not be required to do a full year of internal medicine first. General medicine physicians compete for a limited number of positions and are generally accepted into a gastroenterology training program if there is a need in their province for more GI specialists. The number of gastroenterology training spots at a specific hospital is determined annually based on the needs of the province.
AC C
EP
TE D
Training in gastroenterology consists of lectures, workshops, conferences, and clinical work with an emphasis on the latest scientific advances. After every educational module, usually every six months, the fellow must demonstrate clinical and procedural proficiency in gastroenterology and hepatology to progress in their training. Requirements also include completion of a thesis during training. The quality of individual thesis projects is often of publication quality but because of language and cost, these generally go unpublished or appear only in local or less visible medical journals. At the end of the three years, trainees have to pass a week-long examination in which they evaluate GI patients, perform procedures (EGD, colonoscopy, liver biopsies, laparoscopy), take a written exam, defend their thesis, and answer oral exam questions before a tribunal of gastroenterology professors. For the academic GI programs in Havana, the exam takes place at the Institute of Gastroenterology but for most other provinces, it occurs at their local institution. Once all the requirements are complete, the diploma in gastroenterology is awarded by the Ministry of Public Health. Cuban trainees do not have to pay for any part of their education or their training. In Latin America, however, fellows pay to do a GI fellowship. Occasionally, medical graduates from Latin America come to Cuba to do their gastroenterology training both because of the high quality of the programs as well as the lower cost of training [8]. The faculty that train gastroenterology fellows, as with all physicians in Cuba, are paid a salary by the state. If they are involved in training fellows or teaching medical students, they are paid a supplement based on their academic rank, i.e. instructor, assistant, associate, senior level professor. For faculty to become promoted, they must teach, do research, and/or publish. Medical doctors can become certified “researchers” by taking exams and presenting a dissertation on a topic to become promoted. Faculty may also obtain a PhD from the
ACCEPTED MANUSCRIPT
Ministry of Higher Education based on their accomplishments and their compendium of publications. In this way, they can advance from the equivalent of assistant or junior professors to senior or full professors.
SC
RI PT
Gastroenterology fellows who wish to pursue a PhD degree generally spend an additional 5 years to complete a project. This may be the same project that they did for their gastroenterology thesis or a new one. Their PhD degree is awarded by the Ministry of Higher Education and, like in the US, is contingent on the productivity of the student and may take more or less time to complete. With respect to conventional PhD training (i.e. non-MDs), students first complete five years of university and then apply to PhD programs. Acceptance generally depends on a high GPA. Ph.D. programs are five years and students have an opportunity to rotate through different scientific institutes to choose a mentor and a laboratory. Their graduation thesis is presented to a committee to obtain their degree. It is not infrequent for master’s students and PhDs to receive international grants to perform post-doctoral training abroad.
M AN U
The healthcare system with a focus on gastroenterology
TE D
Each of Cuba’s 15 provinces has a main teaching hospital that offers secondary level care to the people of the province. Most, but not all, of these provincial hospitals have the ability to perform upper and lower endoscopy. There is also a system of peripheral outpatient clinics and smaller hospitals that often have a gastroenterologist, typically with the ability to perform upper endoscopy but generally not colonoscopy. Although the local gastroenterologist can resolve most common issues, she/he has the ability to easily refer patients to a higher level of care if necessary. Nevertheless, the provincial hospitals offer the opportunity to capture data as it relates to gastroenterology because for most complex diseases, such as IBD, most patients would be referred to the provincial hospital for diagnosis and management.
AC C
EP
The medical record of a patient is on paper but is extremely detailed. The record stays with the local primary doctor and when a patient seeks a consultation with a specialist, the evaluation of the specialist is added to the file. In the special case of gastroenterology, several hospitals benefit from an application called “ProGastro” developed by a young Cuban gastroenterologist interested in informatics [9]. ProGastro is a simpler version of our Provation. The physician or assistant enters the type of procedure, the findings, the intervention, whether biopsies were obtained, and eventually the final pathology reading. The application allows for easy searching of the database by diagnosis (picked from a pull down menu) or a text search, which may facilitate research projects. The application is used by several of the larger gastroenterology departments, but not all. On the other hand, the hospitals that have the application tend to serve as referral centers for a large catchment area and may provide an opportunity for collaborative research. In many hospitals, however, the endoscopy data remains part of the patient’s paper chart. Tertiary level care in gastroenterology and most other areas of medicine is available in Havana at several institutions. Cuban gastroenterologists at elite institutions have obtained advanced endoscopic training in Japan, Canada, Spain, and Germany. Depending on the
ACCEPTED MANUSCRIPT
RI PT
need of the patient, the provincial gastroenterologist will refer the patient to hospitals that offer specific services. The Institute of Gastroenterology in Havana has motility equipment, capsule endoscopy, and performs hepatitis B and C viral load testing. The National Center for Minimally Invasive Surgery (Centro Nacional de Cirugía de Minimo Acceso) offers advanced endoscopic techniques including endoscopic ultrasound, endoscopic mucosal resections, and capsule endoscopy. Many of its specialists have trained abroad and offer courses on advanced endoscopic techniques to colleagues in neighboring provinces. Finally, the Hermanos Ameijeiras Hospital is a 1000 bed hospital with tertiary care in most specialties including gastroenterology and liver transplantation.
The biotechnology industry in Cuba
M AN U
SC
Recently, the Cuban public health system placed an emphasis on screening for colorectal cancer. This has been made possible by the development in Cuba of their own fecal immunohistochemical test termed SUMASOHF (Sistema Ultra Micro Analitico para la deteccion de Sangre Oculta en Feces Humanas)[10, 11]. Primary care doctors perform the occult blood test on all patients over 50. The challenge remains providing colonoscopies to patients with positive tests. At present, most patients present with more advanced adenomas or cancers. The country has also provided hepatitis B vaccination trough their primary care network since 1995.
EP
TE D
As alluded to previously, Cuba has a vibrant biotech industry that has developed various vaccines and other technologies. Some of the best known research institutes in Cuba include the Center for Genetic Engineering and Biotechnology (Centro de Ingeniería Genética y Biotecnología (CIGB)), the National Center for Scientific Investigations (Centro Nacional de Investigaciones Científicas (CNIC)), the Center for Immunological Studies (Centro de Inmunoensayo (CIE)), and the Institute of Tropical Medicine ‘Pedro Kouri’ (Instituto de Medicina Tropical Pedro Kouri (IPK)). In addition to a FIT test for occult blood, they have developed a hepatitis B vaccine[12]. Unfortunately, the cost of publishing papers is frequently a barrier to dissemination of their work. In spite of these challenges, several recent biotech developments like Heberprot-P, epidermal growth factor, for diabetic foot ulcers and CIMAvax for lung cancer have gotten the attention of US academia and pharma and are currently in clinical trials in the US.
AC C
Opportunities for research in Cuba There are many wonderful opportunities to partner with Cuba to perform collaborative research. The physicians and scientists are highly trained. The finite number of hospitals offering diagnostic and therapeutic options means that it is possible to obtain prevalence data for specific gastrointestinal conditions. The same is true in hepatology wherein serum from patients with hepatitis B or C is sent to one institute for testing. All institutions have a uniform process for ethics board approval. The perception from Cuban doctors is that their patients are willing to participate in clinical studies if it will help increase knowledge. Of course the important limitation of Cuban healthcare is limited financial resources; thereby restricting access to equipment and medications for patients. Cuban patients have generally not been exposed to expensive medical interventions. In the US it has become difficult to recruit IBD or hepatitis patients that are naïve to biologic medications. By
ACCEPTED MANUSCRIPT
SC
M AN U
Maria T. Abreu, MD Director, Crohn's & Colitis Center Martin Kalser Chair in Gastroenterology Professor of Medicine Professor of Microbiology and Immunology Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine
RI PT
contrast, Cuban patients have generally not received any expensive medical treatments and may therefore benefit from the opportunity to participate in clinical trials. Finally, as exchange with Cuba becomes more commonplace, we can imagine scientific exchange and shared post-doctoral training programs. It is our hope that medicine and science will lead the charge of normalized relations with our Cuban colleagues.
Oriana M. Damas, MD Assistant Professor of Medicine, Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine
TE D
Felipe Neri Piñol Jiménez, MD, MS, PhD Professor and Senior Investigator, University of Havana School of Medicine Master in Infectious Diseases Honorary Member of the Cuban Society of Gastroenterology International Member, American Society of Gastrointestinal Endoscopy
1.
2. 3. 4.
AC C
EP
Roberto Cañete, MD, MS, PhD Director of Matanzas’ Council of Scientific Health Societies Full Professor and Senior Researcher University of Medical Sciences and Center of Hygiene, Epidemiology, and Microbiology. Matanzas, Cuba
Khemlani, A., World Health Organization, Cuba: WHO Praises Efforts and Contributions to Health Education and Prevention. Agencia Cubana de noticias- Latin Post, 2014. Loewenberg, S., Cuba's focus on preventive medicine pays off. Lancet, 2016. 387(10016): p. 327-9. Sosa, O.A., Crece esperanza de vida geriatrica in Cuba. Cubadebate, 2014. Frist, B., Cuba's Most Valuable Export: Its Healthcare Expertise. http://www.forbes.com/sites/billfrist/2015/06/08/cubas-most-valuable-exportits-healthcare-expertise/#1507e133325c, 2015.
ACCEPTED MANUSCRIPT
11. 12.
RI PT
SC
10.
M AN U
8. 9.
TE D
7.
EP
6.
Cobian, C.O., et al., P2.32: Survival Assessment of Non-Small Cell Lung Neoplasia Patients in Advanced Stage Treated With the CIMAvax-EGF Vaccine: Track: Immunotherapy. J Thorac Oncol, 2016. 11(10s): p. S235-s236. Keck, C.W., The United States and Cuba - Turning Enemies into Partners for Health. N Engl J Med, 2016. 375(16): p. 1507-1509. Balbosa, N., Study medicine in Cuba, an option for young people in the world. Granma Newspaper https://translate.google.com/translate?hl=en&sl=es&u=http://www.granma.cu/cu ba/2016-04-08/estudiar-medicina-en-cuba-una-opcion-para-jovenes-del-mundo08-04-2016-16-04-26&prev=search, 2016. García, N.V., La escuela más avanzada del mundo. Juventud Rebelde, 2014. Villa-Jiménez, O.M., ProGastro System http://www.microsofttranslator.com/BV.aspx?ref=IE8Activity&a=http%3A%2F%2 Fwww.ige.sld.cu%2Farchivos%2Fpages%2Fprogastro.html, 2015. Cuba Develops Quick Colon Cancer Test. http://www.cadenagramonte.cu/english/show/articles/12147:cuba-developsquick-colon-cancer-test, 2012. Gonzalez, R.S., Cancer Screening. Global Debate and Cuban Experience. MEDICC, 2014. 16(3-4). Jain, A., et al., A multicentric evaluation of recombinant DNA hepatitis B vaccine of Cuban origin. Trop Gastroenterol, 2000. 21(1): p. 14-7.
AC C
5.