Cuba’s 2020 containment of COVID-19
A comprehensive scientifically-based plan
Cuba was as prepared for COVID-19 as any nation could be. It formulated a comprehensive plan, with various institutions working together to formulate and implement a plan, prior to the arrival of the virus on the island. As a result, the virus was effectively contained in 2020, with two relatively mild peaks. But in 2021, due to various external and internal factors, there occurred an explosion of cases. This high third peak reached its highest level in August 2021, which now appears to be under control. In both stages of the struggle against COVID, Cuba has demonstrated the importance of a united front, with governmental officials continually meeting with scientists and specialists in the development and public dissemination of a coherent plan.
The Containment of COVID-19 in 2020
In late January, 2020, a short time following the confirmation in China that the new coronavirus could be transmitted from person-to-person, Cuban scientists formed two teams, one to assess the knowledge and resources that Cuba had available, and another to focus on the application of measures to respond to the pandemic. They determined that Cuba essentially had the medical infrastructure, personnel, equipment, and medicines necessary to respond, but they possibly were short on hospital beds. So, the Ministry of Public Health established the necessary conditions with respect to hospital beds, making adjustments in the hospital infrastructure and incorporating tourist lodging.
The Plan of Prevention and Control of COVID-19 was approved on March 5, prior to any confirmed cases of COVID-19, which has been adjusted as the situation evolved. Its key components included: the suspension of tourism and international travel; the establishment of isolation centers; the suspension of public transportation; the prohibition of interprovincial travel; the requiring of face masks outside the home and in places of work; the closing of restaurants and stores that sell non-essential goods; the suspension of schools and universities; the formation of teams of medical students for door to door inquiries, searching for persons with respiratory symptoms and for asymptomatic cases; the encouragement of all persons to stay at home, except for work and necessary purchases; the maintaining of physical distancing in stores and public places; handwashing at the entrances to stores and places of work; the placing of all persons who had contact with confirmed cases or who had traveled internationally in isolation centers for a period of fifteen days; and the cancellation or postponement of cultural, social, and political events that involved concentrations of people. The civil defense organizations in the provinces were activated for the implementation of the plan; and the police were authorized to impose fines.
Such a plan could not possibly be coercively imposed. It required, and it had, the support and voluntary compliance, in a spirit of sacrifice for the common good, of the great majority of the people, a phenomenon that was rooted in the legitimacy of established institutions in the eyes of the people.
When the door-to-door inquiries identified persons with respiratory symptoms, they were sent to the family doctor’s office in the area, who determined if the patient should be taken to a local hospital for testing. Samples are taken at the local hospital and sent to a laboratory established for the purpose. Confirmed COVID-19 patients remained hospitalized for treatment. From the beginning, Cuba had at its disposal the drug Interferon Alfa 2B, which has been developed by Cuban Center of Genetic Engineering and Biotechnology, and which had been used to treat with success COVID-19 cases in China.
The Plan was conceived as having three phases. The first or pre-epidemic phase, characterized by confirmed cases of travelers proceeding from affected countries or local cases produced by contact with these travelers. The second phase is that of limited autochthonous transmission, where there are confirmed cases in which direct links with travelers proceeding from affected areas has not been established, but such cases are limited to a locality of the country or a particular center or institution. The third is the epidemic stage, where cases are confirmed without known contacts to previous cases, and there are an increasing number of cases in different localities, disseminated throughout the national territory.
With awareness of the looming threat, from January 25 to March 16, the Cuban medical system began to identify and treat persons with symptoms, hospitalizing some. On March 11 and March 12, the first four cases were detected, all imported.
As of April 3, Cuba was still in the first or pre-epidemic stage. As of that date, Cuba had 288 confirmed cases, and all but seven cases were tied directly or indirectly to international travel. However, on April 5 to April 7, the number of local transmission cases increased, including cases in which the source of transmission could not be identified. Accordingly, on April 7 and April 8, the Minister of Public Health, José Angel Portal Miranda, reported on the need to begin the second phase, which meant an increase in the number of testing laboratories and the setting aside of more hospital beds as well as an intensification of health measures with respect to transportation and retail stores.
By mid-April the Cuban battle against Covid-19 had begun to assume different characteristics. There had been an increasing number of confirmed cases in which the source of the infection could not be traced to international travel, and a corresponding significant increase of cases of autochthonous transmission, located in different provinces. Twenty local transmission events had been declared, and seventeen of these communities had been quarantined, in which all persons in the zone are confined to their homes, and active inquiries seeking to identify sick or potentially sick persons were conducted in all the houses.
The active door-to-door inquiries became increasingly oriented to not only to identifying persons with symptoms, but also those that had had contact with sick persons and may be asymptomatic carriers, transmitting the disease even though they did not have symptoms. As a result of the change in orientation active inquiries, it would subsequently be found that more than half of newly confirmed cases were asymptomatic at the time of their test. The Cuban strategy of actively looking for transmitters without symptoms removed such persons from contact with the healthy, with the intention of reducing the number of confirmed cases later in the cycle of the infirmity.
The peak of the first wave was reached on April 24, with 824 active cases. In accordance with health regulations, many people were working from home via telephone and Internet, or were staying at home on furlough from work, with full pay for the first thirty days and 60% of salary after thirty days. Inasmuch as all public transportation had been suspended, workers in the production and distribution of necessary goods and services arrived to work through transportation arranged through their place of work. Moving toward a decentralization of distribution, large stores and shopping centers were closed, and the people were purchasing necessary items in small stores and stands near their homes.
From the beginning, the government was committed to explaining things to the people. The nightly evening news programs La Mesa Redonda was converted into a daily space for ninety-minute or two-hour explanations by three or four government ministers or scientists. In addition, there were daily morning press conferences by Dr. Francisco Durán, National Director of Epidemiology of the Cuban Ministry of Public Health. The sixty-eight-year-old Durán, with his patient and clear explanations, became a beloved symbol of the Cuban struggle against the pandemic. As a result of thorough and reliable television and newspaper coverage, the Cuban people were well informed about the reasons for the health measures, the contributions of Cuban science to the battle plan, the characteristics of the new coronavirus, and the evolution of the pandemic in the world.
The indiscipline of some with respect to the health measures emerged as a theme of much discussion in Cuba. The government, working in cooperation with a team of scientists and doctors, had formulated a coherent and scientifically informed national plan. But the effectiveness of the plan depended on the compliance of the people. The great majority complied, but there has been a minority that ignores the health rules, apparently not convinced of the risk to themselves and others, which has provoked appeals from the leadership was well as threats of fines and even imprisonment. The indiscipline of some resulted in local transmission events that pushed upward the total accumulated number of confirmed cases, and which ultimately provoked a second wave.
Because of its socialist economy, Cuba’s health restrictions had fewer negative consequences for the people than is the case in many nations in the capitalist world-economy. Cuba has a state-directed economy, in which most companies are state-owned, with space for private self-employment, small scale private capital, and joint ventures with foreign capital. Although Cuba suspended tourism, its principal industry, the economy was able to sustain itself in 2020, by maintaining production in necessary goods and services, including health care, agriculture, food processing and distribution, energy, water, and important export industries like pharmaceuticals, nickel, and sugar. Companies in these sectors got by with a minimum of workers and by arranging for some employees to work from home. Since public transportation was suspended, the companies arranged for bus transportation for their workers with the Ministry of Transportation. Workers in the necessary sectors followed strict hygiene and social distancing measures.
Support was provided by the state to the people during the endemic. Employees in the companies of the state sector who were not working because of the pandemic received full salaries for the first month and sixty percent of salaries after thirty days. Bank loan payments were suspended, and in any event more than 90% of the people own their homes. Utilities in normal times are subsidized and inexpensive, and utilities payments were extended during the endemic. The state analyzed the distribution of necessary goods through the retail market during the pandemic, and it took necessary measures to ensure the distribution of necessary goods and services, including the transfer of certain items from the retail market to the system of state distribution of goods. As a result of such state support, even though many had lower income during the period, many were able to sustain themselves in isolation.
Following the peak of the first wave on April 24, the number of active cases continued to decline throughout May, declining to 145 on May 28. At the daily press conference of May 20, Dr. Francisco Duran was asked by an international press agency to identify a unique aspect of the Cuban response to the pandemic. He responded that what is unique in the Cuban response has been the integrated combination of measures, including: first, the establishment of isolation centers, and the placing in isolation of all confirmed cases, contacts with confirmed cases, and persons with suspicious respiratory symptoms; secondly, the search for the contacts of all confirmed cases, so that they can be isolated and tested; thirdly, door-to-door inquiries, looking for persons with symptoms and persons who may have had contact with confirmed cases, conducted by medical university students with the support of neighborhood organizations; fourthly, testing of a random sample of the population, which is designed to determine the level of immunity of the population, and which thus far also has led to the confirmation and isolation of a few cases; fifthly, the use of preventive medicines for the population at risk, such as older persons; and finally, medical treatment of sick persons in accordance with procedures developed by a team of doctors and scientific researchers.
During the first week of June, Cuba experienced an increase in the number of active cases and in daily newly confirmed cases. However, the scientific advisors to the government believed that a new upsurge was not beginning, and that a gradual decline in the number of active cases would soon occur, inasmuch as the reason for the recent increase was known, as a result of epidemiological investigation. What occurred was that a worker in a store in Central Havana continued to go to work in spite of having symptoms, hiding the symptoms from superiors. This person infected other workers at the store for a period of six days. One of the infected store workers was asymptomatic, without awareness of being infected. He infected his wife, who also was asymptomatic. She infected several co-workers at the pharmaceutical laboratory where she works. In addition, one of the store workers infected others in the transportation provided for the workers. The overwhelming majority of new cases in subsequent days were related to the case at the Central Havana store.
The nation’s leaders emphasized that the Central Havana store event illustrates the importance of compliance with the health measures. Symptoms should be reported immediately. And in addition, since one can be infected without knowing, it is important for everyone to constantly comply with the measures concerning social distancing, hand washing, and the wearing of masks.
On June 11, 2020 the Cuban government announced the beginning of the stage of recuperation. On the daily evening television/radio news program La Mesa Redonda, Cuba President Miguel Díaz-Canel, Prime Minister Manuel Marrero, and Minister of the Economy Alejandro Gil explained the features of the Cuban plan for recuperation. The recovery stage had three planned phases, with movement from one phase to another determined by pre-established health indicators. The designation of phases varied from province to province, inasmuch as there was variation in the rates of infection by province. Thirteen of the fifteen provinces and the Isle of Youth were ready to move to the first phase of the recovery stage, inasmuch as they have not had a single confirmed case in more than fifteen days. Like the Plan of Prevention and Control that had guided the country since March, the Plan of Recuperation was formulated by a temporary team composed of government ministers and scientists and researchers in a wide variety of fields, particularly the medical sciences; led by the President and Prime Minister.
At the June 11 announcement, Díaz-Canel observed that there are a number of indicators suggesting that the pandemic is under control, including the decline in the number of newly confirmed cases and active cases as well as a reduction in the number of patients that are in critical or serious condition. For this reason, the nation can and ought to proceed, with caution and discipline. A 112-page document had been prepared, to assist the people in understanding the measures to be taken during the recovery stage.
Many of the details of the plan were explained by Prime Minister Marrero. He declared that the intention was not to return to normal, but to establish a “new normal,” in which careful attention is given to avoiding a new breakout. Health measures were to be maintained and strictly enforced: cloth face masks when leaving the home, no great concentrations of people, physical distancing, and regular hand washing. The measures were to have greater flexibility in the second phase.
During the recovery stage, workers not attending their work centers for reasons related to health would continue to receive 100% of their salaries. Working from home continues to be encouraged. The suspension of payments for electricity, gas, and telephone was maintained during the first phase; payments for utilities resumed during the second phase.
In accordance with the June 11 announcement, municipal transportation was reestablished, including city buses and all public and private transportation, but under new physical distancing rules and other hygiene measures. Transportation among the provinces was opened, including interprovincial buses, trains and air travel, but under new rules. Self-employed workers could return to their trades and businesses, with health regulations. Schools and universities reopened, under strict hygiene measures.
The two major state-owned retail chains opened for the sale of clothing, footwear, and electrical appliances. Restaurants and cafeterias opened, but operating from 30% to 50% capacity, depending on conditions, in order to maintain physical distancing. Bars were permitted to reopen, but with physical distancing, and dancing with concentrations of persons is prohibited. Parks, zoos, aquariums, and botanical gardens were opened, but with 50% of capacity. Swimming pools and beaches were opened, but with strict regulations to maintain physical distancing. Large parties or concentrations of people were prohibited.
International tourism to the coastal keys was opened, with the intention of opening tourism to the entire national territory during the third phase. International tourists were tested upon arrival, and they were required to fill out a declaration of health. Hotels were restricted to fifty or sixty percent occupancy, and a medical team was present in each hotel.
Reflecting the decline in the number of cases and Cuba’s control of the virus, the government announced on July 16 the transition of the nation to the third phase of recovery, with the exception of the provinces of the City of Havana and Mayabeque, which were to remain in the first phase in the case of the City of Havana and the second phase in the case of Mayabeque.
However, an outbreak occurred at the end of July in the town of Bauta in the province of Artemisa, one of the two provinces that constituted the Havana countryside. The government reacted quickly, placing some 2800 persons in quarantine, isolating 137, and conducting 703 tests in the first day of the outbreak. From July 23 to August 4, there were 85 confirmed cases in Bauta. From July 31 to August 13, there were 101 confirmed cases in the surrounding province of Artemisa.
Epidemiological investigation found that source of the Bauta outbreak was a religious activity. The first case was a woman of 53 years of age with antecedents of diabetes and hypertension, in whose house the activity was held. The activity was celebrated on July 10, attended by 25 persons, 13 of whom contracted the disease. Some of the infected persons subsequently went to a bar in Bauta, converting the bar into a source of infection. The infected persons in the bar who were from Artemisa and from the nearby areas of Havana. Some of the youth later went to bars in Bauta and Baracoa (province of Artemisa), leading to the contagion of persons who had not attended the religious activity. In addition, there were infected persons who attended neither the religious activity nor the bar, but frequently visited the house where the activity was held. Each one of the participants in the activity had a network of contacts between 20 and 30 persons, with the result that more than 3000 persons were placed under specialized surveillance by the Primary Health Care system.
The Bauta outbreak spread to Havana. From July 31 to August 13, there were 365 newly confirmed cases in Havana, an average of 26 per day. Accordingly, the government announced the return of Havana to the phase of limited autochthonous transmission, which means the return to the closing of all non-essential productive and service activities and the stopping of public and private transportation. The return to restrictions was well-accepted by the population, which, taking into account their own observations, was persuaded by the government’s interpretation the new outbreak was caused by the irresponsible non-compliance with the health measures by a few persons.
The government sounded the alarm in mid-August with respect to the noncompliance of some persons with the health measures. In addition to the religious fiesta in Bauta and attendance at bars in Artemisa, there also was a case of pool party and a bar in Havana. And there were other examples: a person with symptoms who went to work; another that evaded a quarantine on the neighborhood; and another that left a center of isolation. The government declared that such examples of lamentable conduct have placed the country in tension and have undermined the common effort of millions of Cubans, among them the heroes who work in the red zones every day. Dr. Francisco Durán observed that the phenomenon of new outbreaks due to irresponsible conduct is not exclusive to Cuba; it is occurring in the entire word. But Cuba, he declared, does things differently from the rest of the world, and the leaderships was expecting better results. He made reference to the door-to-door inquiries, to the application without cost of PCR tests, to the urgent attention and isolation of the sick and their contacts, to the application of innovative medicines, and to the hospitalization of the patients until full recovery. However, when people ignore fundamental and simple elements, like the use of masks, handwashing, and isolation, the risk becomes extremely high. Duran also noted that the majority of cases in recent days has been young people, who do not see the importance of the health measures, perhaps for immaturity, lack of information, or egoistic thinking.
In spite of the evident disappointment of the leadership in the increase of confirmed cases, the second wave of July and August actually had less active (hospitalized) Covid cases. The relatively lower level of active cases was a result of the accumulation of practical knowledge in treatment, so that patients could be released from the hospital more quickly. The accumulating practical knowledge also had the effect of reducing the fatality rate of confirmed cases. All persons in critical condition had the intensive care treatment that they needed; no persons died as a result of the collapse of the system of intensive care, as has occurred in other parts of the world.
Cuba’s infrastructural capacity to respond to the virus was evident in the comparative international statistics of October 2020. Cuba’s 56 cases per 100,000 population was far lower than the corresponding rate in the United States and Europe: USA, 2,496; Belgium, 2018; Spain, 2115; Netherlands, 1453; France, 1389; UK, 1115; Sweden, 1045; Portugal, 1009; Russia, 985; Switzerland, 874; Italy, 719; Denmark, 636; Germany, 450; and Norway, 314. Major East Asian nations did better than Europe: India, 562: Australia, 110; Japan, 74; South Korea, 49; and New Zealand, 39. The East Asian nations constructing socialism did even better: China, 7; and Vietnam, 1. The progressive nations constructing socialism of Latin America also fared relatively well: Venezuela, 302; and Nicaragua, 83; in contrast to Brazil, 2507; and Argentina, 2253.
As of October 2020, Cuba had registered one Covid-related death per 100,000 population, which also indicated a strong performance in comparison with other nations: Belgium, 91; Spain, 73; USA, 66; Italy, 61; Sweden, 58; France, 51; Netherlands, 40; Portugal, 22; Switzerland, 21; Russia, 17; Denmark, 12; Germany, 12; and Norway, 5. In East Asia: India, 9; Australia, 4; Japan, 1. South Korea and New Zealand along with China and Vietnam all had less than 1 death per 100,000 population. In Latin America, Venezuela, 3; and Nicaragua, 2; stood in contrast to Brazil, 74; and Argentina, 60.
A second announcement of the new normality, October 2020
By early October 2020, it seemed clear that Cuba had attained effective control of the virus. Thirteen provinces and special municipality had gone various months without new cases, or with few cases. The provinces of the City of Havana, Ciego de Avila, and Sancti Spiritus remained with new daily cases, but in these provinces the number of active cases was falling, and the situation in these provinces was moving toward effective control. Only one person in the hospital in critical condition, and one person in serious condition.
As a result of the control of the second wave, and taking into account the effective procedures and physical infrastructure that had been developed, the government Covid team believed that the time had arrived to rethink its anti-Covid strategy. Back in In March, Cuba had been in a situation in which it had to confront the virus without knowing it. By October, it could move to the formulation of a new plan, taking into account all the accumulated knowledge and experience in the nation as well as internationally
The new plan, announced to the people on October 8, 2020 involves living with the infirmity. It is a plan that opens economic and social activities, while at the same time strengthening procedures of prevention and treatment, advancing toward a new normality, in which it is possible to live with the infirmity with a minimum of risks.
The new normality includes the wide embrace of a new code of living, with new norms of comportment, accepting the virus as a part of reality, but reducing the risk as much as possible. The people have to maintain a perception of risk, in order to avoid a new breakout. The preventive health measures of the new normality have to be followed in families, in neighborhoods, and in institutions. Primarily, the measures have to be self-enforced on the basis of individual and family responsibility as well as institutional responsibility, in schools, educational centers, factories, stores, and public places. The new norms have to become a daily habit of the people on the basis of a widely accepted ethic of citizen responsibility. In the new normality, Cubans have to learn to greet one another differently, expressing affection while maintaining physical distancing. Meetings of any sort are to maintain physical spacing.
Centers of recreation are open in the new normality, including theaters, cinemas, entertainment parks, game rooms, aquariums, and botanical gardens; but in strict compliance with the health measures and the new code of living. Restaurants and cafeterias are open, in conformity with social distancing and other health measures. However, night clubs and bars will have special regulations; night clubs cannot be like they were before the pandemic, thus diminishing a popular form of entertainment among Cubans and tourists.
In the new normality, urban and interprovincial public transportation is fully restored. Special transportation to health centers for health workers as well as for the treatment of COVID-19 patients is maintained.
In the new normality, PCR testing continues, conducted without charge, for persons with serious respiratory symptoms or who are suspicious for epidemiological reasons. In the new normality, testing capacity is expanded, with each province having at least one testing laboratory.
In the new normality, the use of facemasks remains obligatory. However, compliance is to be attained through the responsible participation of persons. It is a matter of a new style of life in which the need for the use of the face mask is internalized in the consciousness of the person. And frequent hand washing and the disinfection of hands at the entrances to public places is maintained as a requirement.
In 2020, 115,299 persons were housed in isolation centers for fourteen days, as a result of contact with infected persons or contact with persons who had had contact. During their isolation, they were tested regularly, and the state covered the costs for meals, medical attention, etc. Isolation was seen as necessary for the containment of the virus, and it has had the full support of the people. But only 4.6% of the isolated persons were found to be positive. Accordingly, taking this fact into account, and taking into account as well the practical knowledge that has been accumulating during the battle with the disease, the government moved to a strategy of home isolation, in accordance with established health measure and with the participation of the family doctor, and with exceptions for persons who do not have conditions for home isolation.
When there is a COVID-19 outbreak event during the new normality, the appropriate health and quarantine measures and procedures will be adopted in the infected block or area, but the life of the province or city will continue, with its economic and social activities and with the sanitary measures of the new normality.
The new normality maintains the prohibition of attendance at work and places of study all persons with symptoms of COVID-19 and other contagious diseases. All persons with symptoms are be sent to a health-service center immediately. In addition, the encouragement of distance work from home, implemented during the epidemic and recovery stages, will be maintained.
International tourism is open in the new normality, including hotels and private rental rooms, which are required to comply with the health measures. Travelers entering the country are required to fill out a Declaration of Health. In 2020, before vaccines were developed, everyone entering the country, including Cuban nationals and residents and international tourists, had to have a PCR test, paid for by the Ministry of Tourism and the Ministry of Health. Once in the country, international travelers were to remain in isolation for five days, either in their hotel, rental room, or home, pending the result of PCR tests.
With respect to national and international travel, only passengers have access to terminals for airplanes and buses. This measure puts an end to the Cuban custom of large gatherings of family members at airport terminals to bid farewell to Cubans departing for international travel or for residence in other countries.
Similarly, in the new normality, visitation of hospital patients is not permitted, and not only patients with COVID-19. Only one person, designated to accompany the patient, is permitted to enter hospitals. This measure puts an end to a Cuban custom in which considerable numbers of family and friends of patients congregate during visiting hours.
The New Normality Deferred
A little more than one year later, Cuba has not yet entered the new normality. The comprehensive plan announced on October 8, 2020 proved insufficient. It did not anticipate that Cuban international travelers were not prepared to self-regulate five-day home isolation; and it did not foresee that a new, stronger and more rapidly spreading variant of the virus would enter the island shortly before the implementation of a vaccination program. As a result of these factors, a dramatic increase in cases occurred in 2021, far in excess of 2020 levels, reaching its peak in August and obligating the reimposition of restrictions. The Cuban battle of Covid would accelerate in 2021, introducing new challenges. But the revolution would emerge from the battle with new achievements. The 2021 battle of COVID will be the theme of my next commentary of November 9.
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