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The Gates Award for Global Health
[Note: The Bill and Melinda Gates Foundation has announced the establishment of the Gates Award for Global Health, in the amount of $1 million, to recognize an organization that has made a major and lasting contribution to the field of global health. Several participants at the recent Pugwash workshop in Havana, in their individual capacities, decided to nominate Cuba's National Immunization Program for this award, which is being administered this first year by the Board of Directors of the Global Health Council.] The Global Health Council Dear Sir/Madam, In recognition of its outstanding efforts over four decades to ensure that its people as well as those of other countries, and most especially children, are effectively immunized against preventable disease, we are writing to nominate Cuba?s National Immunization Program (NIP) for the Gates Award for Global Health. Writing as individuals, we are nominating Cuba?s NIP having become personally familiar, through direct experience and through Pugwash sponsorship of two workshops on public health issues in Havana (October 1998 and February 2001), with that country?s success in extending the benefits of immunization to the entire Cuban population and others living in low-income countries. Despite the obstacles faced by all developing countries, as well as some unique to itself, Cuba has established an incredibly comprehensive public health care system for its people. According to statistics compiled by international organizations such as UNICEF and the Pan American Health Organization (PAHO), the Cuban public health care system easily surpasses those of almost all other developing countries, and in many respects is comparable to, or even better than, those of many industrialized nations. To cite only two of many examples, medical services are provided to 98 percent of the population (surpassing that of the US and all of Latin America), while 95 percent of the public is attended to by local family doctors, each serving approximately 150 families in their neighborhoods. As a result, Cuba compares extremely favorably with even modern industrial countries when it comes to infant mortality, maternal mortality, life expectancy, and other public health indices. Regarding immunization, Cuba moved aggressively in the early 1960s to implement a national vaccination program to combat those diseases that previously had been widespread throughout the country (e.g., 500 deaths annually from measles, tetanus, and whooping cough; 300 cases of paralysis from polio; tens of thousands of other illnesses that could have been prevented through vaccination). The National Immunization Program was created, based on four essential principles:
In the four decades since then, Cuban health care professionals and medical researchers have been in the forefront of global efforts to eliminate the incidence of such preventable diseases as poliomyelitis (1962), diphtheria (1979), measles (1993), rubella and mumps (1995), while greatly reducing cases of whooping cough, tetanus, and tuberculosis. More recently, great improvements have also been made in developing vaccines and protecting the Cuban people from meningitis B and C, hepatitis B, and influenza type B. Especially noteworthy in terms of the Gates Award for Global Health are the international partnerships that Cuba has developed over the past 40 years in order to bring the experience of Cuba?s vaccination program to other low-income countries throughout the world. As witnessed by Cuba?s current effort in Haiti, described more fully below, we believe that receipt of the Gates Award would allow the National Immunization Program to solidify and expand such regional and international efforts at a time when the country continues to face severe economic constraints. Extraordinary Contributions Toward Progress in the Knowledge and Practice of Health in Low-Income Societies Cuba?s public health care system, through which the vaccination program is implemented, is itself a model of advancing health in low-income societies. By devoting a relatively large part of its GNP (seven percent) to public health (comparable rates for Costa Rica and Brazil are 1.27 percent and 0.64 percent respectively), and because of a genuine commitment on the part of healthcare workers and the government, the country has put in place a comprehensive public health care system despite the existence of widespread material shortages. With one doctor for every 180 inhabitants (comparable rates are 1:480 in the US and 1:450 in the UK), Cuba has put together a network where physicians team up with nurses and healthcare workers in a highly organized, efficient, and evenly distributed network across the country. The end result is the capability to vaccinate the entire Cuban population of eleven million people within 24 hours. An Established Record of Achievement Building upon an immunization legacy that includes being the first country in the world, in 1923, to eradicate smallpox (1977 for the rest of the world), Cuba?s National Immunization Program launched its first National Polio Vaccination Drive in February 1962 for children under 15 years of age. This two-stage campaign was carried out in one-week periods in February and April, enabling Cuba to eradicate polio within four months, also a world record. With the participation of as many as 80,000 volunteers, this initial concept of "national vaccination weeks" has been employed ever since and was initially expanded to include vaccinations against such diseases as diphtheria, tetanus, and whooping cough. In the 1970s and 1980s, similar campaigns were launched, including:
Constant improvements and adaptations to the NIP have allowed Cuba to eradicate a number of diseases while virtually eliminating many others. As a result, infectious disease is not a major cause of death in Cuba as is true in many other developing countries. Similar to many industrial societies, the two primary causes of death in Cuba are heart disease and cancer (leading to a popular saying in Cuba that "we live as poor people, but we die like rich people"). Even here, Cuba?s comprehensive vaccination program is showing results; the Hepatitis B vaccine has reduced the incidence of liver cancer, causing it to drop in ranking as a cause of death. Innovation in Program Design Cuba is the only country to provide protection to its entire population, most especially children, against 12 different diseases. Vaccines implemented in Cuba which are rarely implemented in most developing countries include those protecting against Hepatitis B, meningitis B and H, and influenza type B. As noted above, the National Immunization Program oversees carefully designed and comprehensive vaccination programs (illustrated by the enclosed vaccination calendar). Based on a public health infrastructure that covers even the most remote rural areas and by mobilizing large numbers of volunteers, the NIP is able to carry out concentrated vaccination campaigns of short duration. Taking polio as an example, Cuba continues to conduct two such one-week campaigns twice yearly, covering all children under 3 years of age. The result is that there have been no reported cases of poliomyelitis in Cuba since 1962. Organizational Capacity Cuba?s National Immunization Program is organized in such a way that the entire population can be vaccinated in less than 24 hours. The healthcare network that Cuba has developed over the years includes three elements: 1) individual family doctor practices which serve about 600 people each; 2) a network of community polyclinics serving around 30,000 people each; and 3) a network of major hospitals throughout the country. All three levels work in close collaboration with each other, evenly distributed throughout the country. The result is that nearly 100 percent of the population is covered in terms of vaccination and that doctors can reach their patients in a maximum of 30 minutes, even in the most remote rural areas. Collaboration with Others and Evidence that Contributions
Since 1962, Cuba has conducted international missions overseas in order to provide community health assistance, including immunization, in dozens of countries, including Algeria, South Africa, Ghana, Angola, Honduras and Nicaragua. One current example of such efforts is Cuba?s collaboration with Haiti in a major immunization program. In cooperation with the government of Haiti, the Pan American Health Organization, and France (which provides the vaccines), Cuban health care specialists have been working with their Haitian counterparts since 1999 to design a nationwide vaccination program. The third stage of this effort is scheduled for March 2001, when over 400 Cuban health professionals will participate. The immunization campaign in Haiti is focusing on those preventable diseases where Cuba already has extensive experience: poliomyelitis, tuberculosis, measles, diphtheria and tetanus. Cuban health care workers and their Haitian counterparts are implementing many of the same strategies that have already proved effective in Cuba, giving particular attention to rural communities which are easily neglected by any poorly organized health system. Another example of Cuban international collaboration is the recent agreement with SmithKline Beecham (now GlaxoSmithKline) to conduct clinical trials of a meningitis B vaccine, of which Cuba is the sole manufacturer in the world. The vaccine was developed at the Finlay Institute (named for Carlos Finlay, a pioneer in the eradication of Yellow Fever at the turn of the century), one of Cuba?s premier medical research centers. In this particular case, SmithKline Beecham and the Finlay Institute have received permission from the US Treasury Department to market the vaccine, when available, in the United States. On the other hand, because of the US embargo, stringent conditions were imposed on how the Finlay Institute may receive royalties, and there is no assurance that future vaccines developed in Cuba will likewise be available for use by Americans. Substantial Impact on World Health Cuba?s contributions to world health through years of assistance to various countries, and through the research and development of various vaccines on the part of Cuba?s outstanding medical research facilities, speak for themselves. Likewise, the current vaccination effort with Haiti, and its implementation in other countries in the Caribbean and Latin America, could make a dramatic impact in greatly reducing the prevalence of preventable diseases. It is our firm belief that, with adequate resources and building on its four decades of experience, the National Immunization Program could bring its immunization expertise to an even wider array of peoples and societies in developing countries. Future examples of such efforts could encompass the development and dissemination of vaccines for AIDS, cholera, dengue and other diseases. Researchers at Cuba?s Center for Genetic Engineering and Biotechnology and the Carlos Finlay Institute are making substantial progress in these and other areas, with the promise of making such treatments available at low cost for people living in developing countries. We should add that we understand the potential difficulties, because of the US embargo and Treasury Department restrictions, of the Gates Award being awarded to Cuba?s National Immunization Program. All we can say in this regard is that we hope the political difficulties inherent in such an award will not preclude the NIP from being considered. Also, we believe that solutions could likely be found for awarding the monetary prize, perhaps in part to organizations working with the NIP on international vaccination programs (e.g., the Pan American Health Organization and donor countries in supplying vaccines; recipient countries like Haiti or others where the vaccination programs are implemented), and also in part to the NIP itself in terms of non-monetary goods and services. In closing, we would like to stress that we believe Cuba?s National Immunization Program is deserving of the Gates Award for Public Health precisely because of the excellence it has achieved despite facing severe economic and political constraints. For a country like Cuba to have developed the National Immunization Program as only one component of a comprehensive public health care system, is testament to the kind of emphasis on health care excellence and equity that we believe the Gates Award will come to symbolize in the years ahead. We appreciate having had this opportunity and want to thank you for your efforts on behalf of global health. Sincerely yours,
Co-Nominators:
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