Improving the US and Global Pandemic Response: Lessons From Cuba

Sandro Galea, MD, DrPH; Paul C. Erwin, MD, DrPH


Am J Public Health. 2023;113(4):361-362. 

At this point, it is abundantly clear that the global response to the COVID-19 pandemic has fallen far short of what we might have hoped. More than six million people have died globally from COVID-19, with more than a million of those deaths in the United States. The United States has had more deaths by far than any other country worldwide. Although there probably is no one country that can claim to have performed well in all dimensions of its COVID-19 response, there are some countries that did better than others on important dimensions of the response, and it behooves us to start the process of learning from these countries toward the end of improving both US and global responses in the inevitable event of future pandemics.

Such lessons can be drawn from the recently published report "Cuba's COVID-19 Vaccine Enterprise: Report From a High-Level Fact-Finding Delegation to Cuba."[1] This international delegation was organized by Medical Education Cooperation with Cuba (MEDICC), a US-based nonprofit that promotes health-related dialogue and collaboration, especially between the United States and Cuba.[2] Cuba had substantially lower mortality during the COVID-19 pandemic, with about 750 deaths per million, comparable with New Zealand, a country that has often been spotlighted for its handling of the pandemic. The report is an efficient summary of Cuba's success in two particular dimensions during COVID-19 that contributed to its weathering the pandemic as well as it did: Cuba's ability to develop an effective vaccine rapidly, and its ability to subsequently vaccinate a large portion (> 90%) of its population quickly. Although we leave it to the reader to read the MEDICC report, we suggest that there are three key observations that emerge from the report that are helpful to bear in mind as we consider how to improve the US national pandemic response.

First, much of the success of vaccine development and vaccine delivery built on decades of investment in both areas. Rapid vaccine development was possible because Cuba has been investing in its biotech sector for 40 years. This has had previous successes (e.g., vaccines against Haemophilus influenzae type b and serogroup B meningococcus) on which the country was able to build its COVID-19 vaccine development. This history of prior investment in biomedical technology is not substantially different from such investment in the United States, and both rapidly yielded effective vaccines. However, Cuba has also invested in a primary care system that provides the infrastructure for delivery of health care on which vaccination efforts were built. We have long known that access to a primary care provider is one of the central determinants of vaccination; that access, long built into the Cuban health care system, has become invaluable for the delivery of vaccines. Moreover, Cuba's primary care system served as the vehicle for its COVID vaccine clinical trials, allowing for countrywide implementation, with results immediately available to the Ministerio de Salud Pública (Ministry of Public Health) for subsequent scaling up and widescale deployment.[3]

Second, Cuba's successes were dependent on national central investment and coordination both of vaccine development and delivery efforts. This is in stark contrast with US efforts, which were characterized by deeply fragmented systems, particularly when it came to vaccine delivery. Cuba here clearly has the advantage of being a much smaller country than the United States. However, US states that are smaller than Cuba suffered from fragmentation of service delivery, showing that size was not the only factor leading to the failure of the US COVID-19 response. Rather, a lesson from the Cuban experience is that it is difficult to deal with an epidemic without a national coordinated response that applies standards across the country in a manner that is data-driven and evidence-informed. Cuba was able to do that in part through a history of building a centralized health care infrastructure that provided the pillars on which a nationally coordinated response could be built. That should offer much encouragement for a careful consideration of comparable centralized efforts to deal with future epidemic responses in the United States. In retrospect, one of the shortcomings of the initial US COVID-19 vaccine delivery was the failure to include primary health care providers; because of the trust people have in them, their involvement from the outset might have prevented much of the subsequent vaccine hesitancy we have experienced.

Third, the ongoing economic and social isolation of Cuba because of US-imposed restrictions hindered both Cuba's and the world's efforts to respond to the COVID-19 pandemic. Cuba was developing approaches, including vaccines, that could have helped global efforts to vaccinate as large a proportion of the world's population as possible, as quickly as possible. These efforts were available principally to countries with preexisting ties to Cuba and offered little help to the broader global community. Because US restrictions on Cuba extend to other countries, those without preexisting ties to Cuba could not benefit from either the Cuban vaccines or boosters. Similarly, the isolation of the Cuban scientific community resulted in fewer articles published documenting the successes in Cuba, therefore limiting the lessons learned and the generalizability of the Cuban experience. Conversely, as has often been the case because of its economic isolation, Cuba was inventing approaches to dealing with COVID-19 out of whole cloth, not benefiting much from approaches—including vaccine technology—that were gaining rapid prominence in the United States and other countries. In the context of a pandemic that does not respect artificial human-made borders, the persistence of human-made limits on commerce and knowledge hampers our ability as a global community to adopt the best possible strategies, incurring loss to human life in the process.

It is always important when discussing medical and public health successes to ask, at what cost was success achieved? This is particularly the case in a country like Cuba, whose communist political system has been opposed by the United States for more than 60 years. And yet, the development of effective vaccine and vaccination efforts has little to do with political systems and should not diminish our interest in learning from Cuban approaches, or our commitment to helping Cuba build a healthier country, grounded in human rights. One might hope that a global pandemic can be the catalyst for transcending both borders and long entrenched political perspectives that can hold back health both in Cuba and in the United States.