Cuba ’ s response to COVID-19: lessons for the future

Purpose – The purpose of this paper is to examine the relevance of Cuba’s medical system, its health tourism and related diplomacy in the context of the recent COVID-19 pandemic for the global response to disease outbreaks. In addition to Cuba being a destination for leisure tourists in the Caribbean, the renowned Cuban medical system attracts thousands of health tourists seeking low-cost but high-quality treatment. This paper demonstrates how Cuba’s unique response to the pandemic, which included sending thousands of medicalstaffabroad,caninformstructuralandglobalissuesandcontributetoamoresustainablefuture. Design/methodology/approach – The research in this study is primarily drawn from published academic and media sources that address Cuba’s medical system, its health tourism and the government’s response to the recent pandemic. The author, a political scientist and an author of many publicationsonCuba, andthePIofa studyfocused onCuban tourism,will also draw onherexpertise. Findings – This paper addresses the Cuban Government’s ongoing response to the COVID-19 pandemic and places this response in the context of Cuba’s medical system, its health tourism and related diplomacy. It reveals key lessons from Cuba’s response for other tourist destination states and, more broadly, for the worldwide response to global outbreaks and the management of health systems. Thefindingswill furtherresearchindiplomacyandtourismaswell as informpolicy and practice. Research limitations/implications – This paper explores an ongoing topic and thus further research will be required following the pandemic. Practical implications – This research note offers important implications for practice including providing accurate, research-based information that challenges misinformation about Cuba’s health system, its medical diplomacy program, health tourism and its response to COVID-19. It offers valuable lessons for public health authorities including the importance of preventative health measures, community medicine and the benefits of working globally to combat outbreaks through the sharing of medicalstaffand resources.


Introduction
The coronavirus pandemic tests us all, but nowhere has it highlighted the resilience of humanity more than in the small tourist destination state of Cuba.COVID-19 revealed Cuba's vulnerabilities but also exhibited the strength of the Cuban health system and its medical internationalism.Cuba's economy is largely reliant on tourism and the government's decision to close its borders on March 24, 2020 intensified Cuba's economic troubles brought on by the recent tightening of the American embargo.Yet, despite simultaneously undergoing the most devastating economic recession in decades, Cuba's pandemic response offers important lessons for the worldwide handling of disease outbreaks and the management of health systems.Although Cuba's response to the pandemic is multifaceted, this paper will illustrate in particular how Cuba's healthcare system and medical diplomacy set Cuba apart during the crisis.Not only has Cuba's response to the pandemic been widely praised but it has allowed Cuba to reopen to tourism and possibly mitigate the economic crisis intensified by the pandemic.

Cuba's tourism industry
Tourism as an industry in Cuba took off in the 1920s when Cuban tourist ads told Americans that Havana was "So near and yet so foreign" (Firmat, 2010).In this period, Cuba was the most popular tourist destination in the region (Elliott and Neirotti, 2008).
Following the Cuban Revolution in 1959, tourism declined most significantly because of the rising tension between the Cuban and American Governments and the eventual imposition of the US embargo in 1962.Once American travel to Cuba became illegal, Cuba lost its major source of tourist revenue.
While a few Canadians and Europeans continued to visit the island, and visitors from Eastern Europe picked up, tourist arrivals were very low in the 1960s and early 1970s, rising only slightly in the 1980s.However, because of the economic crisis brought on by the end of the Cold War Cuba refocused on tourism in the early 1990s.At this time, the government moved to open tourism to more foreign investment, establishing joint ventures with European, Mexican and Canadian hotel and tourism companies to increase Cuba's capacity as quickly as possible (Duffy and Kline, 2018).
The number of visitors has continued to rise, returning Cuba to its status as one of the most popular destinations in the Caribbean, even though it has remained largely excluded from the American market.Cuba normally draws over 4 million visitors each year (2016, 2017, 2018 and 2019), but the pandemic has caused the numbers to decline to just under 1 million visitors in 2020 (Trading Economics).Tourism in Cuba, like elsewhere, is in crisis.However, Cuba's management of the pandemic has not only improved the health outcomes of Cubans and those it aids abroad, but it has also allowed the country to reopen to tourism.
Cuba's response to COVID-19: internal measures COVID-19 first arrived in Cuba in March 2020 with three Italian tourists.They were diagnosed on March 11, the country was in "lockdown" mode by March 20, and by March 24, Cuba had closed its borders.
Cuba's lockdown entailed the closure of schools and businesses, mandating masks and the isolation of COVID-19 positive patients, among others.Most significantly for the economy, Cuba closed the border which brought an abrupt halt to tourism, one of the country's primary sources of foreign exchange.

Case numbers and comparisons
While differences in testing protocols, case counting and death reporting make comparisons difficult, it appears that Cuba managed the pandemic better than most of the other states in the Caribbean and much better than many wealthier states.By January 10, 2021, Cuba had a total of 14,576 cases and 151 cumulative deaths (13 deaths per 1 million people) (Worldometers, 2021).Compare that to Jamaica with 312 deaths (105 deaths per 1 million people) or the Dominican Republic with 2,427 deaths (223 deaths per 1 million people).By this same date, the USA had reached 1,151 deaths per 1 million people (Worldometers, 2021).By most measures, Cuba has performed extraordinarily well during j JOURNAL OF TOURISM FUTURES j one of the most challenging periods in its history.The primary credit for this success has been given to Cuba's unique community-based medical system.

Secrets of success: community-based medicine and biomedical research
Cuba's health indicators are impressive both when compared to other states with similar Gross National Products and when set beside much wealthier countries including the USA.For example, Cuban life expectancy at birth (2018) is 79 years, which exceeds other states in the region, such as the Dominican Republic and the Bahamas where it is 74 years (World Bank, 2020a).Moreover, life expectancy in Cuba is the same as life expectancy in the USA.The recent figures for infant mortality are similarly impressive (4 per 1,000 live births); the same as the UK and Canada and better than the American figure of 6 per 1,000 (World Bank, 2020b).
Cuba has free universal health care and prioritizes access to medical personnel and preventive medicine.At 84 doctors for every 10,000 individuals, Cuba has the highest ratio of doctor-to-citizen in the world.By this measure there is a substantial difference between Cuba and the USA, which has a mere 26 doctors per 10,000 people (WHO, 2020).
It is not just the number of medical personnel but also the unique way they deliver their services that have contributed to Cuba's impressive statistics.The heart of the Cuban health-care system is the local neighborhood of approximately 1,000 individuals.Resident in each neighborhood is a family physician and nurse who provide care to the local population and emphasize preventive health education.

Community based medicine: the pandemic response
This ease of access of the Cuba population to medical staff, information and treatment was a significant factor in Cuba's ability to manage the pandemic.The well-honed neighborhood medical system that rapidly implemented a systematic door-to-door medical survey allowed the Cuban state to quickly identify and isolate cases.This system, known as Continuous Assessment and Risk Evaluation (CARE) is integral to the Cuban model as medical teams regularly go houseto-house to discuss everything from diet to disease treatment with their patients (Gorry, 2020).Furthermore, symptom canvasing also occurs during dengue or other outbreaks.
The canvassers received additional training on identifying COVID-19 symptoms in January, two months prior to the arrival of the virus on the island (Aguilar-Guerra and Reed, 2020; Gorry, 2020) Thus, soon after the first cases had been reported, the entire population of the country had discussed COVID-19 with a medical expert.This system has facilitated efficient contact tracing, isolation and testing.
Cuba's model, already widely acknowledged as innovative, is being accorded accolades for its pandemic response.An article in the Journal of the Royal Society of Medicine declared, "With a health system grounded in public health and primary care, the country invests heavily in producing health workers who are primarily trained to work in the community, [. ..]Their efforts with COVID-19 have been outstanding" (Ashton, 2020).Likewise, an article in Medicc Review asserted "the backbone of Cuba's universal public health system is also the backbone of its response to the Coronavirus pandemic" (Aguilar-Guerra and Reed, 2020).Public health officials in other countries should take note of Cuba's CARE model and its success, not only in containing the spread of COVID-19 but also of the positive effects of preventative health measures and community medicine on the overall health of the population.In the spring of 2020, Cuba received the highest evaluation for its pandemic response from the Oxford Stringency Index (Hale et al., 2020;Oxford, 2021).

Biomedical research
The health-care system also benefits from Cuba's exceptional investment in biomedical research and planning.In January 2020, Cuba began to organize its virus response plan, j JOURNAL OF TOURISM FUTURES j formulating solutions for possible scenarios and expanding laboratory capabilities (Ashton, 2020;Pe ´rez, 2020).
Cuba is perhaps best known for its innovative research on vaccines, including a vaccine that treats lung cancer, but it has also developed medicines in many other categories.This experience was harnessed during the COVID-19 outbreak when seven of Cuba's biomedical research facilities transitioned to focus on COVID-19 vaccines and treatments.

Cuba's international response: medical diplomacy
Cuba has a long history of medical diplomacy, reaching back to the 1960s when the country sent a team of medical workers to Algeria during its war of independence.Since then, Cuba has frequently responded to international disasters with its medical personnel, treating patients in the Caribbean after hurricanes or in Africa during the height of the HIV/AIDs crisis.Since 2005, the process has been coordinated through Cuba's rapid response medical team, the Henry Reeve International Medical Brigade.Consisting of over 7,000 medical personnel, it is designed to quickly respond to crises around the world, aiding populations in dozens of countries undergoing natural disasters or epidemics.
These missions are widely admired.In fact, President Obama was impressed by Cuba's efforts and noted that when Latin American leaders "spoke about Cuba they talked very specifically about the thousands of doctors from Cuba that are dispersed throughout the region, and upon which many of these countries heavily depend" (Wylie, 2012).Former UN Secretary-General Ban Ki-moon called Cuban doctors "miracle workers" (Ban, 2014).In 2017, Cuba received the WHO Public Health Prize in recognition of these international endeavors.
Cuba's global response to the pandemic has been extraordinary.Cuba sent its medical teams to Wuhan in January 2020 and shortly thereafter a team went to Italy where they built and then treated COVID-19 patients in a field hospital in Lombardy (Ashton;Doctors, 2020).During the pandemic, Cuban teams helped in dozens of countries in Latin America and the Caribbean, Africa, Asia, Europe and the Middle East (Cuba Minrex, 2020).
Likewise, Cuba accepted the British cruise ship MS Braemar that was turned away by other countries because it had COVID-19-infected passengers onboard, prompting praise by the British ambassador to Cuba and the British foreign secretary (Stone, 2020).
Recognition is widespread.The head of CARICOM, Ralph Gonsalves, explained, "They are lifesavers, [. ..]In some Caribbean countries, they constitute the backbone of the response to the pandemic" (NBC News, 2020).In the summer of 2020, over 30,000 people campaigned to nominate these Cuban medical teams for a Nobel Peace Prize.One of these people, Noam Chomsky declared that Cuba was the "only country to have shown genuine internationalism during coronavirus crisis" (Donmez, 2020).

Vulnerabilities impeding Cuba's response to the pandemic
Despite its success, Cuba's ability to respond as effectively as possible to the pandemic has been hampered by the ongoing economic crisis principally brought on by six decades of American hostility.President Trump's tightening of the American embargo reversed many of the changes initiated by President Obama, which further damaged the Cuban economy just in time for the pandemic.Trump also targeted Cuba's medical internationalism during j JOURNAL OF TOURISM FUTURES j the outbreak by pressuring receiving states to refuse Cuba's offer of medical aid (The Guardian, 2020).While all of Cuba's economic woes cannot be blamed on American hostility, it is the most obvious single challenge to the Cuban economy, worsening poverty and hampering Cuba's ability to weather the pandemic.
Cuba's relative poverty creates three main stumbling blocks in a pandemic.First, Cuba suffers from a severe housing shortage, which leads to overcrowding and complicates the population's efforts to social distance (Borkowicz et al., 2017).Second, because Cuba is dependent on other countries for most of its food, the pandemic has worsened food insecurity (Marsh, 2020).Third, the poor condition of some basic infrastructure such as roads and communication networks hampers the state's otherwise effective response to crises.In particular, the relatively underdeveloped internet and e-commerce systems on the island have impaired Cuban citizens' ability to purchase necessities online and thus reduce community contact.However, the pandemic has brought attention to these problems, spurring change, including the development of an e-commerce platform devoted to the hospitality sector (Carrero, 2020).

Return to tourism
Cuba's relatively successful management of the pandemic has allowed the country to welcome tourists again.The government began with a phased reopening on June 1, allowing the resumption of domestic tourism, followed by a partial reopening of international travel to isolated keys adjacent to the mainland on July 1.Access to the keys are restricted, thus limiting contact between Cubans and visitors.Cuba's most popular resort area, Varadero, reopened on October 15, along with many other areas of the country, excluding Havana.The government's phased opening was meant to control and monitor the return to tourism.
Cuba has made many changes to protect tourists and Cubans they encounter through the "Turismo þ Higienico y Seguro" (more hygienic and safe) program, which regulates and monitors tourist facilities for disease prevention protocols (Kucheran, 2020).Furthermore, tourist hotels are now staffed with a doctor, nurse and epidemiologist (Harris, 2020).Thus, Cuba's first planeload of tourists arrived in Cayo Coco on September 4, reflecting confidence in Cuba's management of the pandemic.The government has continued to update protocols since, instituting airport testing and as of January 10, 2021, mandating a prearrival polymerase chain reaction (PCR) test for most visitors (Frank, 2021).
Cuba, Ministry of Tourism of Cuba (2020) is using Cuba's new protocols and low numbers to promote Cuban tourism in a new advertising campaign called "Breathe" and with the #CubaYourSafestDestination (see www.facebook.com/MinturCuba.ca/videos/1564261290419773).As Cuban economist, Ricardo Torres explained, "Cuba's very successful strategy in controlling the epidemic is also an asset when it comes to opening up, [. ..] because the tourists in the coming months will be looking for safe destinations from a health perspective" (Cuba Reopens CGTN [2020]).This approach also builds on Cuba's reputation as a health tourism destination.In addition to vaccinating its population and donating its vaccines to poorer countries, "Cuba is floating the idea of enticing tourists to its shores with the irresistible cocktail of sun, sand and a shot of Sovereign 2 [Sobreana 2]." (Augustin and Kitroeff, 2021) Although this strategy shows promise, it is too early to measure the success of the new campaign and further analysis of the impact of the return of tourism on the spread of the disease will also need to be conducted.

Lesson learned: in Cuba and globally
The Cuban state acknowledges that it could learn from its response to the pandemic.In particular, the state said the pandemic helped it to identify how the country could improve its readiness for future crises, including strengthening Cuba's e-commerce and home delivery services and increasing domestic production of essential goods.j JOURNAL OF TOURISM FUTURES j More importantly, there are significant lessons for other countries from Cuba's pandemic response.The Cuban example shows the benefits of a robust but low-cost community-based medicine program and the benefits of working globally to combat outbreaks through the sharing of medical staff and resources.Cuba's medical diplomacy demonstrates that a state's response during crisis can moderate the global inequities and injustices such as unequal access to care that often accompany disease outbreaks such as COVID-19.