A strong and continued commitment to a free public health system with universal access, and an emphasis on preventive healthcare have underpinned Cuba’s response to the pandemic. This article has been originally published in Pandemic Discourses. 

Prologue

In 1995, during what is known as the Special Period, following the collapse of the Soviet Bloc, I met with Fidel Castro in his office in Havana. At that time Cuba was being encouraged to expand its ties with other Latin American countries and to integrate more within the region. When I asked him about this possibility, he paused and replied quietly: “When I look out at Latin America, I see three things: rising inequality in every country, a deteriorating environment in every country, and no consensus in any country about how to address these problems. Surely we can do better than that.” If this conversation would have been held in 2020, I am sure that he would have added COVID-19 to the list.

The global outbreak of COVID-19 has presented an interesting challenge for Cuba-watchers. With its vaunted strong public health system, how would Cuba fare in the pandemic era? Facing its own version of an economic recession for 60 years, namely the embargo on foreign trade illegally imposed by the United States, would the pandemic induce similar economic effects as seen elsewhere? A third question concerned the distributive impact of the virus. Would the virus affect “the poor” in Cuba more than the average person as had happened in many other countries? Taken together, these questions suggest a broader inquiry into why the Cuban experience with COVID-19 has been so successful compared to many other countries.

The Pandemic

COVID-19 arrived in Cuba in mid-March 2020, much as it did in other places in the western hemisphere. The Cuban government’s strong border controls discovered several Italian tourists at the Havana airport who subsequently tested positive for this virus. These numbers increased slowly as the trickle of foreign tourists was monitored closely. Positive cases were isolated and then hospitalized.

The authority of the government was clear and decisive, reflecting not only its own governing style, but also its prior experience with the spread of HIV-AIDS 40 years earlier when it had quarantined people with HIV-AIDS. Between mid-March and end-June, the government reported 2,348 cases and 86 deaths. The country also reported an increase in respiratory illness, but these were not formally qualified as COVID-19 cases. On June 9, the government declared that the pandemic was under control, following nine days without any deaths. While political opponents in Miami have challenged these numbers, they have not provided any public evidence that the numbers are incorrect.

Cuba’s approach reflected its preventive health system. Cuba has developed a very high ratio of 8.19 doctors per 1000 people, in contrast to 2.6 for the United States and 2.15 for Brazil. Doctors are normally available in all neighborhoods for routine diagnosis and treatment, including psychological support. I remember visiting some of these local health offices in 1987 and being told by an elderly woman patient, “I come here every morning for a kiss. It makes me feel good.”

One report suggested that two months before its first case, Cuba was already sending doctors to follow up on all cases of respiratory ailments and maintained the contact tracing after the first case of COVID-19 was found. A Ministry of Health spokesperson noted that identifying cases before serious symptoms could be observed was a way to stop the spread of the disease. This labor-intensive work is also part of an economic system where most people work for the government.

In early July 2020, the government announced Cuba was open for tourism, but that it would send all tourists directly to one of five tropical isles, avoiding Havana and other population centers. Each tourist is tested for COVID-19 before being allowed to go to these tourist sites.

So the answer to the first question is that the Cuban public health system has proven to be a robust and effective response to COVID-19. But the follow-up question is why.

Cuba’s health system has long been a central feature of a country that was heavily affected by the United States’ embargo that started in 1961, following the nationalization of US property and the Cubans’ claim for the end of exploitation by US private companies. Cuba was forced to look inward, to develop a social policy to address the needs of a mostly poor population. It guaranteed basic needs for the population, including health, education, food, and housing.

This approach to state provision led to allocating significant resources to health, including training of doctors and nurses, adopting an active policy of preventive health care, and investing in biotechnology and scientific research to both provide for the Cuban population and to generate foreign exchange. This led to the discovery of Interferon, a drug that was first used to treat some cancers and later revealed to have value in treating other diseases. Indeed, Interferon was sent to China after the outbreak of COVID-19 in Wuhan.

Cuba’s good performance in controlling COVID-19 also followed its approach to natural disasters. Despite being located in a hurricane zone, Cuba was recorded in 2004 as having the lowest per capita mortality rate of any country as a result of natural disasters. This reflected the civic preparedness and education starting in kindergarten. Children have known what to do and have been trained to follow government instructions. This fits into a wider pattern of a well-organized country, including at the block level with the Committees for the Defense of the Revolution (CDRs), political units with obligatory membership by all residents.

Economic Consequences

The economic impact of the virus has not been so positive. With the border closed, Cuba has been unable to maintain its flow of remittances from the US, Latin America, and Spain. This produced a sharp economic contraction in March-April 2020, with most investment projects stopped, households short of cash for increasingly scarce food and other items, and the collapse of the tourism-based economy that was generating a large share of foreign exchange. Many “informal” workers in the tourism economy, in Havana and in the beach resorts, suddenly lost their incomes.

These impacts added to an already disastrous economic situation resulting from the policies of the Trump administration in tightening the embargo and eliminating flights to all cities outside Havana.  Added to this has been the impact of the continuing collapse of Venezuela and its inability to maintain oil exports to Cuba. Energy shortages in Cuba have slowed down industrial production, transport, as well as the pace of needed economic reform.

Together, COVID-19 and the embargo have resulted in worsening shortages of essential foodstuffs, medicine, soap, toothpaste, and many other products. The so-called “mules,” transporters of medicine, machinery, spare parts, and other key inputs to Cuba, have also been unable to travel, stopping an important source of inputs.

The gradual opening of the tourism industry will help earn needed foreign exchange, but the hopes for tourism development after the Obama diplomatic opening in 2016 have been dashed by Trump and set back further by COVID-19.

The Distributive Impact of COVID-19 in Cuba

In contrast to most countries where the pandemic has had a disproportionate impact on the poor, Cuba has not had this problem because the disease is generally not distributed across income groups as there is very little difference in the nominal incomes of households across the country. Incomes from public employment are about US$25-$30 a month, or $300-$360 a year per capita. Informal sector workers, like all Cubans, are also assured of subsidized rent, food rations, education, and health care. Nonetheless, food shortages tend to reward higher income households who can afford black market prices for scarce products. Another caveat to this conclusion is that there is severe overcrowding in housing in Havana and that limits the possibility of social distancing. This, however, seems to be balanced out by the aggressive Cuban preventive health care policies and approaches.

Towards a Broader Conclusion

In most countries COVID-19 has been a game-changer, but not in Cuba. Despite a significant number of cases and deaths, the pandemic has not deeply upset the standard of living and way of life. The government remains very much in control, despite the fact that many Cubans have left the country seeking a better life and better protection of human rights.

If Fidel had lived to see the pandemic, he would have been proud of Cuba’s response. Indeed, Cuba did do better. It demonstrated that a strong and continued commitment to a free public health system with universal access and a preventive rather than a curative orientation to public health has huge benefits as new health problems arise. This system has been in place for almost 60 years and has demonstrated its reliability and quality. It has been protected from the uncertainties resulting from the US embargo. Cuba is justifiably proud of its public health system and has even exported its approach to other developing countries, sending doctors to Bolivia, China, Ethiopia, Nicaragua, Venezuela, Vietnam, and many other countries, including to Italy during the COVID-19 outbreak.

Michael Cohen is Professor of International Affairs and Director of the Doctoral Program in Public and Urban Policy at The New School. He has visited Cuba 25 times from 1987 to 2019.