By: Aaron Plourde, Advance Access & Delivery (AA&D)

Over a two-day workshop held April 26-27, senior level health officials from Cuba met with Duke Center for International Development (DCID) faculty, staff and students, along with representatives from Advance Access & Delivery (AA&D) – a nonprofit public health NGO headquartered in Durham, the Indiana Recovery Alliance – a harm reduction organization based in southern Indiana, UNC-Chapel Hill and Harvard University to discuss potential future work and collaboration related to health delivery and service provision in different settings.

The discussions focused on strengthening health care delivery for vulnerable and marginalized populations through the lens of the tuberculosis (TB), opioid epidemics, and social services for immigrant communities. Guests and speakers included Dr. Lourdes Suarez-Alvarez, head of the Cuban National TB Program; Dr. Raul Diaz-Rodriguez, head of Cuba’s National Reference Laboratory of TB; Dr. Jorge Pérez, adviser to the Cuban Ministry of Health and former head of Pedro Kourí Tropical Medicine Institute (IPK); Tom Nicholson MIDP’14, AA&D executive director and associate in research at DCID; Dr. Salmaan Keshavjee, director of the Harvard Medical School Center for Global Health Delivery-Dubai and vice president and senior clinical lead at AA&D; Phyllis Pomerantz, professor of the practice in the Sanford School of Public Policy; Jon Abels, DCID executive director; and Christopher Abert, founder of the Indiana Recovery Alliance.

“This is an opportunity to learn from the global south, where most innovations are coming from,” said Pomerantz, who kicked off the discussions. “There are countries where proposed solutions have been tried but were not successful. In Cuba, we see there has been success and other countries can learn from their solutions.”

Urgent public health challenges

This event highlighted two touchstone issues that underline the difficult work of social and health services reaching marginalized and vulnerable people. Every day, roughly 4,900 people die from tuberculosis (TB), or a total of 1.8 million deaths each year. In 2015, there were an estimated 10.4 million new TB cases (incidence). Though the disease has been nearly eliminated in the United States and other western countries, TB is now the leading infectious killer of adults worldwide.

Meanwhile, in the United States, opioid use and overdose is fueling the worst drug epidemic in the country’s history. Opioid overdose is now the leading cause of accidental deaths in the U.S., with more than 33,000 people losing their lives in 2015 alone.

These drivers of early death and disease disproportionately affect vulnerable and marginalized people across the world. Both issues are fraught with stigma and often make it more difficult for patients to seek appropriate care, and both face public policy headwinds that can undercut elimination efforts.

Cuba’s success in driving down TB

Cuba has some of the lowest TB rates — both for incidence and mortality — among any country in the world. According to Cuba’s Ministry of Health, the country had a TB incidence rate of 6 per 100,000 people, and a mortality rate of .4 per 100,000 people in 2016. As a comparison, the World Health Organization (WHO) reported that U.S. rates in 2015 were 3.2 and .18 respectively, and global rates were 142 and 19 respectively. 

Members of the Cuban delegation attributed its success to the country’s comprehensive epidemiological control strategy for diagnosing, treating and preventing TB. Additionally, they pointed to Cuba’s commitment to providing holistic, community-based care where doctors and nurses are closely involved in the lives of patients as a key driver for improving TB and general health outcomes. These practices make it a strong example that others could follow in the fight against this deadly infectious disease, attendees agreed. The case to emulate Cuba’s strategies is made stronger by the fact that the small island nation has achieved this despite periods of intense resource scarcity, particularly during the 1990s when Soviet aid was discontinued and TB rates tripled.

“The Cuban case shows that a community based health system that focuses on prevention and social support is particularly well positioned to end TB as a public health menace, even in challenging conditions,” said Nicholson. “Certainly, more money will need to be spent around the world to achieve this, but by using this approach the benefits will clearly extend far beyond any single disease.”

Eliminating TB through a comprehensive strategy

Many participants from both Harvard, UNC, AA&D, and DCID are affiliated with the  Zero TB Initiative and Zero TB Cities Project, which were founded to help create ‘islands of elimination’ of TB through a comprehensive epidemic control strategy known as the Search, Treat, Prevent Approach. Through the initiative, cities, regions, or even islands fight TB by actively searching for people with the disease, providing preventive therapy to people infected with TB and those belonging to high-risk groups, controlling TB transmission by routinely using the right tools for early and accurate diagnosis, providing immediate and appropriate therapy, and ensuring supportive programs are in place to help keep patients on therapy.

“For a long time, we in the public health community have ignored tried and tested epidemic control strategies, largely because of cost,” said Keshavjee. “Cuba is proving what can be achieved when there is real commitment and follow through in using a comprehensive strategy for controlling and eliminating TB.”

The initiative works to help communities move toward elimination in their own way and support is provided as needed through founding partner organizations, including AA&D, Harvard Medical School Center for Global Health Delivery-Dubai, Interactive Research & Developments and The Stop TB Partnership. It works to assist programs and encourage exchange between cities like Karachi, Pakistan; Chennai, India; Lima, Peru; Kisumu, Kenya; and others.

Delivering high-quality care

Throughout the two days, participants discussed strategies for improving access to high quality health care and medicines, particularly for economically and socially marginalized groups. Both the Cuban delegation and U.S.-based members agreed that future collaboration on TB and other diseases would be mutually beneficial and committed to further engagement.

“Events like this help to strengthen new platforms for south-south collaboration, while also informing wealthier health systems facing huge challenges of their own,” said Nicholson. “This is a very exciting first step.”

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