Ileana Morales from the Cuban Ministry of Public Health speaks to Outra Saúde, about the country’s renowned biotechnology sector, the impact of sanctions, and the future of health care as newer forms of technology emerge. The first part of the interview, which focuses on Cuba’s response to COVID-19, can be read here.
Outra Saúde: Can you tell us a little more about Cuba’s biotechnology and pharmaceutical industry?
Ileana Morales: Farmacéutica y Biotecnológica de Cuba is a business group that functions as a large cluster. It is a state-owned company that includes 32 high-tech, IT, and logistics companies. Previously, these companies used to be major research centers, like the Center for Molecular Immunology, the Center of Immunology, the Center for Genetic Engineering and Biotechnology, the Center for Neuroscience. In other words, these major research centers are now also high-tech companies.
It is a large group that is present internationally, with branches, and companies in other countries. It employs around 30,000 workers, many of whom hold PhDs and Masters degrees. They are companies, but beyond that what characterizes them most is that they serve the purposes of public health. They address two major areas: health and agriculture. They work to make products for health—diagnostic tests, medicines, medical equipment, supplies. They also produce, to a lesser extent, diagnostics and pharmaceuticals used in precision agriculture.
What we have is a great alliance, unique in the world, which is only possible because it is a state company. It is not based on market thinking. We are permanent allies in fact, the science group that I coordinate and the industry coordinator—who is a great academic. This is because we have the same interests. The industry produces medicines and equipment for the basic health needs of the Cuban population.
There is a basic framework, inside which every year, we make demands for the medicines and supplies that we need. The industry fulfills about 70% of these needs, the other 30% are imported—those that are not part of the production or development line. In a country that is focused on production for the benefit of its population, this of great impact.
OS: How does the economic embargo imposed by the United States affect this production?
IM: You can’t talk about health, you can’t talk about development, or anything else in Cuba without exposing the context of the blockade. I am an optimist, so I like to say that if all this is happening despite the embargo, imagine where we would be without it. We have a very large human potential in the country, we have built enormous capacities in the 60 years after the revolution, we have a strong university network, an inter-institutionality that doesn’t exist in other countries, and an inter-sectoriality.
But the consequences of the embargo have a huge impact, especially on health. I think the impact on health is the most tangible and most objective indicator of how cruel, unfair, inhumane, and illogical the blockade is—you can use all the adjectives you want to describe this 60-year old wound. It is something that we Cubans feel from the moment we get up to bedtime. But I repeat: this will not take away our joy, our optimism.
In a way, the ability to pursue local development comes from the blockade—if it is possible to see a good side in it—as we have to be more creative, more innovative, multiply the loaves and the fishes. Everything we have, we take advantage of. We try to make the most of medical equipment. Our medical engineers spend all day long repairing equipment or inventing a spare part—because sometimes, we have nowhere to buy spares, since the United States has hegemony over this equipment. We can’t buy equipment or products that include 10% of parts from the US. Sometimes we have to search far away to find equipment, and sometimes we don’t lack equipment, but we lack spare parts.
Despite all this, we keep going. We have a lot of innovative, creative people who spend their days working to maintain the health care system. But you can’t ignore the fact that the embargo is a big problem.
OS: How is the training of health professionals in Cuba organized?
IM: Cuba has the highest ratio of doctors per inhabitant in the world. We have more than 100,000 doctors for a population of 11 million – 9.2 for every 1,000 inhabitants. We also have the highest ratio of health workers per inhabitant – 500,000 overall. But it’s not that we have leftover professionals. We don’t have so many doctors because we like training them, but because we have a health policy that employs all of them. This includes those who are in management positions and those who are committed to our international solidarity missions, our collaboration in health.
Another point in our favor is that the medical universities are public and belong to the Ministry of Health. We plan our human resources, train them, and employ them. And we continue training them while they work, so they are prepared for everything. Nobody else does this, it’s a model specific to our country. The health worker enters the system at the age of 17 and stays until she retires. It is very beautiful, because the first year student already feels like a health worker, because she sees the teachers doing this service.
We also have a training system based on the concept of Primary Health Care. Since the 1980s, Cuba has complied with all the Alma Ata guidelines to have a strong, accessible system. In 2023, more than half of the countries in the world are still not complying with this project. Unfortunately, some scientific articles report that until 2015, one billion people in the world had never seen a health professional.
We summarize our approach to this topic in three simple words: access, equity and solidarity. Cuba has set up its system of training, organization of health services, and research on these three major concepts.
OS: How do partnerships with other countries work, like the Mais Médicos program with Brazil?
IM: We do a lot of international collaboration. Cuba has been there to support others during all the major health disasters. During the Ebola crisis, Cuba was one of the very few countries that sent medical brigades in Africa. We are always present during earthquakes, fires, and floods. And we always favor communities where most of the time there are no health workers, or we go to places that lack healthcare services. This is the vision of Cuban medical collaboration, which is implemented through two main channels: health workers’ training and provision of care.
OS: What is the impact of new technology, such as artificial intelligence and big data, on Cuban health?
IM: I am particularly excited to see how the students will react to these changes. I recently wrote an article about ChatGPT. New technology is here to stay, and I believe we need to be receptive to them. We need to know how they come in, and where they come in. We need to know what they are for.
I’m going to be blunt: technology is no good for one-on-one care in Primary Health Care. In my opinion, technology doesn’t work here because it doesn’t allow the doctor to touch the patient, to provide the care, and to have a complete view. For this area of work, I don’t want ChatGPT, or another chatbot that the person accesses through a device while the doctor is away in his office. This won’t do for the type of medicine practiced in Cuba, which is done with warmth, with ethics, and with humanism.
What is technology good for? To add value to what we do, to the medical act, to scientific, scientific-epidemiological, and clinical-epidemiological thinking. This is where technology comes in, and where we work hard to develop our own artificial technology. Of course, it is not as developed as the existing ones, but we are working on its improvement.
We also work with nanobiotechnology, the biotechnological ranges. There is a group that studies nanomedicine. We are working intensely on nanomedicines and nanodiagnostics. We have a medical robotics group. We study regenerative medicine, which takes a lot of bioinformatics and big data.
We work a lot with bioinformatics, with the management of the big databases that we have in healthcare, trying to convert the data into information to produce new drugs. We also use these new forms of technology to train students, using it as a didactic tool—to help them study instead of stopping them from studying. We are thinking about developing a new study plan to reflect about the post-COVID-19 world.
OS: Recently you said that the hospital is going to end. What did you mean with that?
IM: I am convinced of this. There are many experts in the world who think that the importance of the hospital is going to decrease significantly and that the care is going to be provided closer to home, at the patient’s bedside. Goodbye hospital. This is an international trend, it’s not something that I invented.
In the case of Cuba, we have been thinking and strengthening home care capacities for years, trying to reduce hospital admissions. All the conditions that are not terribly serious or do not need the use of many tools, we treat at the primary level—which is strong in our country.
This is related to a conceptual problem, too. When medicine is commercialized, doctors order a lot of unnecessary X-rays, imaging, ultrasounds, and MRIs. This is an expense for the system, but it is done because health insurances are charging. In the case of Cuba, which has a different system, we use the least amount of medicine possible, the least amount of diagnostic methods possible, and instead do a lot of clinical epidemiology. Most of the patients who come to the health system actually need simple things.
Cuban medicine, from the point of view of health economics, is much cheaper. This is a very therapeutic teaching. The hospital is a living organism that can get sick itself. It is toxic in every way – from the psychological implications it brings to the issue of hospital-acquired infections.
We are talking about different paradigms. There is one paradigm that is centralized, hospital-based, and another that community-based—which is ours. What most doctors measure today is the disease. There are others, of course, mostly public health experts and family doctors, who at least consider risk when they think about health. But there is still a leap further from there, which is Positive Health. Positive Health starts from the moment before the risk exists so that from birth and throughout life, there is prevention and health promotion. This also has a lot to do with environmental and cultural issues. What can the environment do to people? What can they do to the environment? This is another thought on which we are working a lot in Cuba – the One Health approach and transversality.
The interview with Ileana Morales was conducted by Fabiano Tonaco Borges, Gabriela Leite and Leandro Modolo, and published in Portuguese on Outra Saúde.
People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.
