As the Medical Director for the Royal New Zealand College of General Practitioners Dr Bryan Betty is an important leadership voice for general practitioners. He is also well placed to draw up his rich experiences as a GP working in Porirua which includes many patients with high levels of deprivation.
Dr Betty has a regular column in the fortnightly New Zealand Doctor magazine which I always make a point of reading because of his valuable insights. This was no less the case than his paywalled column (26 May) on Covid-19 vaccine development. He begins with the observation that GPs see infections every day in their communities and that they deal with the complexities of rolling out nationwide vaccination programmes.
Noting that Covid-19 is likely to be with us forever and that most likely future vaccines will be necessary to deal with “rogue variants”, he then issues a dire but sound warning: “New Zealand will always be subject to the whims and environmental pressures of international vaccine production, and the politics and competition for supply is likely to increase.”
Dr Betty points out that vaccine development is already happening in New Zealand and believes that we presently have the technology to develop and produce new animal vaccines. This leads him to conclude: “New Zealand can and should proactively prepare for future Covid-19 scenarios by building capacity to manufacture one or more vaccine platforms in the country…” Failing this New Zealand should work with commercial vaccine developers to complete the last steps of manufacturing.
The critical requirement to enable vaccine development, as Dr Betty correctly identifies, is government support and investment to “…fully resource the scientific expertise and high-level research facilities needed to make human vaccines for our population.” He aptly describes this as “future-proofing” New Zealand’s vaccine capability for future variants and other pandemics.
When one, including presumably Dr Betty, thinks of vaccine development in response to the coronavirus pandemic one usually thinks of the big overseas pharmaceutical companies (‘Big Pharma’) primarily based in the United States and Europe. Many think of profit maximisation. Vaccine production has always been profitable but, until the pandemic, less profitable than other drug products and therefore underinvested in.
Many also think of patents (used to obstruct the development of cheaper generics) and Big Pharma’s attempts to use ‘free trade’ agreements to interfere in countries sovereignty over drug purchasing such as disabling Pharmac’s effectiveness in New Zealand.
What one doesn’t think of is a small Caribbean island country of over 11 million people that for over 60 years has been subjected to economic warfare (officially called an economic blockade but let’s call a spade a spade) a metaphoric hop, skip and jump away from the world’s biggest economic and military powerhouse. Despite this precarious position Cuba offers lessons for New Zealand in the context of Dr Betty’s call.
The Washington Post has observed that Cuba could become a “coronavirus vaccine powerhouse”. Cuba’s vaccine innovations have also impressed the internationally prestigious medical journal The Lancet.
Cuban health system ethos
Cuba’s vaccine development should be seen in the wider context of the ethos behind its approach to healthcare. There are three broad priorities in Cuba – health, education and culture (including revolutionary heritage) for which its economy is required to support rather than the other way around.
Since the 1960s Cuba has had a proud history of overseas medical humanitarian missions. In early 2009 I observed a snippet of this in rural Santa Cruz in Bolivia. These missions began in 1965 increasing in the number of participants over the years, including the 2013-16 Ebola crisis in West Africa. Within one year of the pandemic, 57 brigades of medical specialists had treated 1.26 million Covid-19 patients in 40 countries (including Italy); they joined 28,000 Cuban healthcare professionals already working in 66 countries.
Cuba’s long-standing commitment to health has led to a successful pandemic response. Its health system has a strong population focus through community-based polyclinics. The nearly 500 polyclinics provide primary care (including dental) along with specialist outpatient and other less complex hospital services, each serving defined populations of between 20,000 and 60,000 people (almost like large neighbourhoods). Their population sizes are similar to New Zealand’s smallest DHBs such as Tairawhiti, Wairarapa and West Coast (a little smaller than Whanganui and South Canterbury). It means that they know their populations well and likely better than most, if not all, of our DHBs.
Cuba has had a sharp appreciation of the importance of workforce capacity in labour-intensive health systems. According to the World Health Organisation (WHO – 2016-17 data) Cuba is the world leader for medical doctor-to-population ratio at 82 per 10,000 compared with 26 in the United States and 30 in New Zealand.
This combination of polyclinics servicing relatively small populations and strong health professional workforce capacity (with doctors and nurses embedded in their communities) means that residents receive annual routine check-ups including any vaccinations. Home visits are made where this can’t be done in the polyclinic (the doctors will find you is a sometimes used friendly expression). This annual well-resourced routine enabled health professionals to promptly undertake Covid-19 testing.
Cuba’s pandemic response
Like New Zealand Covid-19 infections reached Cuba in March 2020. Also, like New Zealand, Cuba adopted an elimination rather than mitigation strategy towards community transmission which proved to be successful in both countries in 2020. They were two of the few countries where the per capita death rate per one million population was single digit. Contributing to Cuba’s success was its ability to mobilise over 28,000 medical students to lead a screening programme that reached nine million out of over 11 million Cubans.
I have previously published, in the Democracy Project (July 2020) on Cuba’s successful response to Covid-19(at the time even more impressive than New Zealand given the brutal economic blockade the country faced). It was largely due to Cuba’s years of investment in primary care and assiduous focus on population health.
But in January 2021, as borders were prematurely opened, many Cubans living abroad returned (including from countries with high infection rates), social life became more flexible, and infections increased significantly. The death rate per 100,000, according to WHO data (30 May) has increased to 8.3. By international standards this compares favourably (161.0 in the Americas and 83.0 in Europe) but not by Cuban standards (New Zealand is 0.5 while Australia is 3.6).
In February alone this upsurge led to almost twice as many new infections as occurred in all of 2020. This was a sharp lesson on the risks of complacency following the implementation of successful elimination strategies, something which New Zealand has also experienced but on a proportionately much smaller scale and which Melbourne is presently experiencing more severely. Nevertheless, despite the effects of economic warfare and greater dependence on tourism, Cuba could benefit by learning from New Zealand’s vigilance over borders and community transmission.
A less known feature of Cuba’s health system is its highly developed and unique biotechnology sector initiated by a forward-thinking Fidel Castro in response to the American blockade. He advanced the idea in the early 1980s with six researchers in a small Havana laboratory. Being entirely state-funded and owned meant that it was free from private interests. Today it comprises over 30 research institutions and manufacturers under the state-run conglomerative BioCubaFarma. Specialising in vaccine development is an important part of this initiative and it has been praised by WHO. Cuba developed the first meningococcal B vaccine later in the 1980s, produces eight of the 10 routinely used vaccines in the country, and sends hundreds of millions of vaccine doses abroad.
Profits are not sought domestically (internationally priced to be as close to production costs at most) and innovation is channelled to meet public health needs. The sector is helped by collaboration with several Cuban research and development institutions that share resources and knowledge. This, including not competing for resources, enables speedier progress from research and innovation to trials and application.
These principles behind Cuba’s biotechnology have proven vital in the development of its Covid-19 vaccines which the country has considered essential in the context of the United States’ economic warfare and the powerful influence of Big Pharma. Cuba now has five different vaccine candidates currently being clinically trialed for Covid-19 of which three are almost ready subject to WHO approval. Results are reported as encouraging.
The names of these vaccines are linked to Cuban revolutionary culture and national pride. Soberana01 and 02, and Soberana Plus are being developed by the Finlay Institute of Vaccines in partnership with the Centre for Molecular Immunology. Soberana means ‘sovereign,’ reflecting its economic and political importance. That is, without a domestic product, Cuba would struggle to access foreign vaccines either due to the economic blockade or to the cost.
The other two vaccines, Abdala and Mambisa, are produced by the Centre of Genetic Engineering and Biotechnology. Their names are tributes to Cuba’s struggle for independence. Abdala is the title of a poem of a Cuban revolutionary while Mambisa is named after the guerrillas who fought against Spanish colonialists in the 19th century.
The vaccines are being tested as they are developed on healthcare workers as authorised ‘interventional studies’ subject to demonstration of drug safety. Through an agreement with Iran’s Pasteur Institute, 100,000 Iranians will take part in the Phase 3 clinical trials for Soberana 2 and another 60,000 people will participate in Venezuela.
Cuba is also collaborating with China to work on a new vaccine called Pan-Corona, designed to be effective on different strains of the coronavirus. Cubans contribute experience and personnel while the Chinese provide equipment and resources. The research will take place at the Yongzhou Joint Biotechnology Innovation Centre in Hunan Province. The aspiration is to be able to protect against epidemiological emergencies of new strains of coronavirus that may exist in the future.
There are five types of COVID-19 vaccines being developed globally. Viral vector (including Oxford AstraZeneca and SputnikV), genetic (including Pfizer and Moderna), inactivated vaccines (including Sinovac and SinoPharm), attenuated, and protein. The five Cuban vaccines are protein. They contain proteins from the virus which trigger an immune response.
The conditions in Cuba enable the small country to produce these vaccines on an industrial scale. They are described as cheap and easy to store. While requiring three doses they don’t require costly refrigeration equipment. The expectation is that they will have an efficacy rate of 80-85% (less than Pfizer and Moderna but well about the 50% international threshold). Some are already being produced for large-scale health interventions.
Implementation of mass vaccinations should be made more practical than most countries due to Cuba’s strong network of family doctors and its government’s communication campaign. Both appear to be making Cubans confident about the vaccine strategy. Hearts and minds are everything as New Zealand experienced with its ‘team of five million’ in the national and local shutdowns. Cuban hearts and minds are no less strong and unified which is cause for optimism among its health professionals. One immediate benefit is the ready oversupply of volunteers for clinical trials.
Using emergency legal provisions vaccination has begun in Havana with the target of reaching 700,000 citizens over 19 years of age in June. By the end of August the target is to vaccinate the remaining one million of Havana´s population. Other provinces are also scheduled to be immunised with a target of 70% of the population by August and 100% by the end of the year.
Responding to Dr Betty’s call
The absence of the profit motive characterises Cuba’s domestic and international response to Covid-19. It is set to be among the first nations to vaccinate its entire population. By the end of summer (our winter) the expectation is that Cuba will have the capacity to produce 10 million doses of vaccines per month.
Cuba’s accomplishments are more extraordinary given that from 2017 onwards, United States under President Trump punitively unleashed 240 new sanctions, actions and measures to tighten the 60-year blockade of Cuba, including nearly 50 additional measures during the pandemic which cost the health sector alone over $200 million. This includes raw materials needed for vaccine development. It even effects the supply of equipment as basic as syringes. While Cuban health professionals are rated highly, the infrastructure they have to work in and with is decayed which hinders their effectiveness. To date, there is no sign of improvement under President Biden.
Despite this Cuba has gone on the offensive against the pandemic. It has mobilised its prevention-focussed, community based public healthcare system to carry out daily house visits to actively detect and treat cases and channelling the medical science sector to adapt and produce new treatments for patients and Covid-19 specific vaccines. Cuba intends to export successful vaccines to poorer and less economically developed countries that can’t afford to vaccinate their populations at high prices demanded by Big Pharma.
Cuba can certainly learn from New Zealand’s tight public health measures response to Covid-19. But New Zealand can learn much from Cuba’s more community focussed health system and superior health workforce investment.
There is also merit in activating discussions with Cuba about how New Zealand might develop its own government supported vaccine development free of profit-driven drivers. This might include collaboration between the two countries. This is important because, as Dr Betty has observed, coronavirus and its increasingly contagious variants are going to be threatening both countries for some years.
Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Democracy Project