Dr. Marcos Espinal is chief of the Department of Communicable Diseases and Health Analysis at the WHO's Pan American Health Organization (PAHO) in Washington, D.C. He was previously executive secretary of the WHO's Stop TB program and earlier held positions in the Dominican Republic's Ministry of Health. Espinal trained as a pediatrician in the Dominican Republic and, starting in 1989, pursued his master's and doctoral degrees at the University of California, Berkeley with support from Fogarty's flagship AIDS research and training program. He has published more than 100 papers about communicable diseases.
What is your role in outbreaks such as Zika?
PAHO is an agency that catalyzes, bringing together scientists from different countries in the Americas. We also have some of the best expertise to assemble technical guidance for countries on how to address TB, HIV, Chagas and many other diseases. When we don't have the necessary expertise, we convene technical advisory groups of experts from outside PAHO. That is what we are doing with the Zika outbreak. PAHO has arranged meetings with representatives from many global partners, including the CDC, with FIOCRUZ in Brazil, our mother organization the WHO, and with the NIH, academia, people from the South and from the North, to discuss research questions that we urgently need to answer. To address these problems means we must be strong in advocacy and communication, to convince governments to spend more money for health matters. Scandinavian countries devote 15-20 percent of their budgets for health, but in Latin America, many countries still allocate below 5 percent. We need to ensure that health is at the top of the development and political agenda of our region's leaders. After all, they need money to implement public health programs, to vaccinate their population and to pay their health workers.
How critical are partnerships to global health?
Partnerships are the number one issue in my view, because we live in a globalized world, in a time when communication is powerful, data are information and power. With social media/email/Internet availability, you cannot hide anything! So you need to be ahead of the curve, in terms of knowledge and information, because the situation can change hourly. Importantly, not one agency knows everything. Partnerships bring a value-add with knowledge coming from different institutions and they also help us to avoid duplication, wasting money - which is not unlimited - and make sure we maximize the available resources. We provide leadership by convening, bringing everyone together around the table to ensure we get the best answers.
How has Fogarty training prepared you for this?
It has been for me a defining experience in my career. Being at Berkeley and being a Fogarty Fellow is indescribable, because I learned so much, I created so many networks. I was honored to be able to work not only for the WHO, PAHO and the New York City Health Department, but also for my own country. More importantly, I became very knowledgeable about public health internationally, not only technically but also politically, strategically and so on. I would define my career as 'Before' and 'After' Fogarty! There was not much opportunity before. As I finished my residency training in pediatrics in the Dominican Republic, I didn't have the financial resources to pay for advanced training at Berkeley or any other U.S. college of that level. Fogarty gave me the opportunity of my life, professionally. It opened up my world completely, gave me another view and I fell in love with public health and research.
What are the most pressing research needs?
Among the biggest global research needs are concerns about the mosquito that is transmitting Zika, dengue, chikungunya, and other diseases. It is a genius to be able to carry all these viruses. We need to do a lot of research on vaccines, diagnostic tests and new antivirals. Sometimes we tend to forget diseases that are limited to small population groups or are not prone to spread like HIV, until the viruses become very aggressive, which happened with Ebola. I think the international community needs to face that emerging and reemerging infectious diseases are here to stay and will continue coming. We also need to find better tools for mosquito control and to eliminate malaria. But we also must keep focus on TB and HIV. We have gone a long way with antiretrovirals, but TB remains one of our highest disease burdens. The treatment time for TB is six months and who wants it to take so long? And we need an efficient vaccine - there are about 10 in clinical trials now.
How does capacity building make the world safer?
To me, Fogarty has been one of the success stories in terms of capacity building for people from resource-limited countries. Diseases don't respect borders and if we don't collaborate, we will not be able to battle these diseases, some of them very new, some of them very old but still not solved. So for me, Fogarty needs to continue doing what it does for decades to come, because there is so much need in resource-limited countries and Fogarty is making a massive contribution to training there.
How has your research training contributed?
It helped me a lot. It gave me the vision that research never ends, there will always be questions. What I am trying to accomplish is to provide my 10-cents to improve the lives of the people in Latin America and the Caribbean - contributing with catalyzing research, by networking with organizations nationally and internationally, with Ministries of Health to ensure they implement proper public health programs on infectious diseases, that they are fully informed. All to reduce the incidence of disease to ensure the people of Latin America enjoy better, healthier lives.
Why is research training important?
The U.S. has been a leader of research in academia, with NIH at the forefront, and it's something to continue and strengthen. I think Fogarty's doing a great job by training people from countries without the resources. We all need to be grateful for Fogarty. Training has a massive role in the future success. Many of trainees are going back to their home countries. I went back home for four years to make a contribution. And now I'm doing it from an international agency but many Fogarty trainees are going back to their countries to contribute. This is something the U.S. should be proud of and Fogarty should be proud, because it's putting people back into their societies, giving them the opportunity to build further. Many of us in poor countries don't have that opportunity. But there are so many brains in our countries and Fogarty is making a massive contribution by bringing together people that could not only help their countries but also could contribute to the international community to advance the health research agenda.
Why did you decide to work at the WHO?
In my medical training, I was attracted by the WHO, the work they did in smallpox, polio, vaccine-preventable diseases, how they worked in many countries, including mine, helping people to get better lives, preventing mortality. It was very humble work, in my view, so I wanted to give more, not only to my home country but to the international community. The WHO was a vehicle for someone not from the U.S. or the U.K., a person from the South. It was a tremendous opportunity for me to contribute.
How might science gain from closer U.S. and Cuban relations?
It will mean a very good opportunity for collaboration. Cuba has a long tradition of research and has some of the best researchers in the world. We recently helped arrange a symposium here in the U.S., which was a tremendous opportunity to bring together around the table scientists from both countries. Not only will they be able to form partnerships to help each other and their countries, but also countries in Latin America, by bringing potential solutions and research questions that need to be answered, or health problems that indeed are a priority today. Now, we're talking about emerging and re-emerging infectious diseases as a priority, chikungunya, Ebola, Zika, Marburg and Lassa fever, and others. So if we are able to put together scientists, not only from Cuba and the U.S., but also from Brazil, Argentina and Colombia and forget about politics and focus on how can we advance the health agenda or the research agenda, that's a major step in the right direction. Yes, it's true, sometimes politics plays a role, but this symposium was a very good example of the willingness of our two countries to move forward, regardless of the politics around.
Do you see faster progress on TB?
The WHO just published a new strategy suggesting tuberculosis cannot be seen as a medical problem, it is a social problem, a problem of the poor. The approach to tuberculosis is intersectoral. PAHO has a pilot project called "TB in Large Cities," because if we don't involve the mayors and community leaders in large cities where people live in crowded housing, and also leaders of the private sector so they take ownership to the approach to tuberculosis, we're not going to be able to solve the problem. TB is about eating properly, living in clean and safe conditions, having access to efficacious medicines, and it's also about research and development. Slowly the international community is coming on board, but we need to shorten the treatment time for TB, produce new vaccines, and ensure we have new diagnostic tests, because the bug that produces TB has been fooling us for 4,000 years or more. It's important that we keep paying attention to tuberculosis because it's killing millions and millions. If we produce new tools and combine that with the engagement of society, of different sectors of the government, there is light at the end of the tunnel.