Cuba Successfully Halts Its COVID-19 Outbreak
LATIN AMERICA AND THE CARIBBEAN, 30 Nov 2020
A Reflection of the Socialist Revolution and the Legacy of Fidel Castro’s Vision of Health Care
25 Nov 2020 – ‘Private medicine grants privileges to those who have money to the detriment of those who do not have it and nothing could be more inhumane than that. It is unbelievable that rich societies that apply this and many other similar policies speak of human rights and humanity when their own system is the most inhumane, the most egotistic, the most individualistic and the most alienating’ (Fidel Castro, Havana, 1999).
‘Man can’t be a piece of merchandise nor can human health be a piece of merchandise, because selling, trading, profiting from health is like selling, trading and profiting from slaves, trading and profiting from human life…’ (Fidel Castro, Havana 1998).
The success of Cuba’s healthcare system is widely acknowledged, even among the country’s adversaries, critics and enemies. However, little credit is given to Fidel Castro’s role and vision in bringing it to fruition. Before the triumph of the Socialist Revolution, Cuba faced persistent shortages of medical workers and had few hospitals. In fact, Cuba’s many poor people often had no access to healthcare services whatsoever, particularly those residing in rural and remote areas of the island. Meanwhile, it was not uncommon for people to sleep on the floor at the few hospitals that the country did have. This is because doctors mainly served ‘the owners of the sugar mills, [and] the millionaires,’ mostly in Havana (Fidel Castro Havana, 2002). Fidel Castro (Havana, 2002) described the state of health care in Cuba prior to the Socialist Revolution as ‘a crime against the people, against the sick, against the unfortunate, against those who suffer.’
Accordingly, one of the main goals of the Cuban revolutionaries was to establish a good health care system that would be available to everyone. In fact, they believed that it was the duty of the Revolution to provide the people of Cuba with excellent universal health care services. Shortly after the Revolution prevailed, the government essentially launched an ‘attack against diseases,’ and implemented measures so that the nation could effectively ‘save thousands of lives from tetanus, diphtheria and whooping cough, diseases that kill thousands of children every year, and can be caught by any child in any family’ (Fidel Castro 1962). On October 17, 1962, Fidel Castro stated that this would be accomplished by:
preventing these diseases through vaccination. And in this way we will continue to combat disease after disease, and will go on decreasing the number of epidemics, the number of deaths, the number of victims. In this way we will work at fulfilling this worthy goal: to move from therapeutic medicine to preventive medicine.[i]
Since the early days of the Revolution, Fidel Castro was determined to have more students enter into medical school each year so that Cuba could, one day, boast more doctors per capita than any other country in Latin America. However, he was well aware that a good health care system and improvements in ‘medicine or the medical power of a country are not only measured by the number of doctors,’ but also by ‘the way these doctors are trained,’ their knowledge, as well as their spirit (Fidel Castro Havana, 1999).[ii] Ultimately, he wanted the country to have an abundance of well-trained doctors, who were also good human beings.
Fidel Castro advanced the socialist government’s efforts to improve Cuba’s health care system by establishing new medical schools throughout the country, introducing new services and ideas, sending family doctors to remote areas, building and expanding hospitals and polyclinics, and investing in scientific research. Now, ‘good doctors and the best specialists are at the service of all the citizens in whatever part of the country’ they reside, and regardless of the income they earn (Fidel Castro Havana, 1998).[iii] The island has transformed itself into ‘a genuine medical power’ that provides extraordinary services in Cuba and abroad.
To fully appreciate the extraordinary achievements of Cuba’s socialist regime in the area of health care, it is sufficient to examine some current health statistics. In 1962, there were only 3,960 doctors in all of Cuba. Today the country boasts one of the highest doctors per capita in the world. In 2019, it was reported that ‘Cuba has more than 100,000 doctors, the highest number in the history of the country with a proportion of nine doctors per 1,000 citizens.’[iv] That same year, ‘there were 91,375 physicians in Canada, representing 241 physicians per 100,000 population,’[v] or 2.4 doctors per 1,000 citizens. Moreover, Cuba currently produces enough medicines to meet about 90% of the island’s total needs. In October, Doctor Eduardo Martínez Díaz, president of the BioCubaFarma[vi] enterprise group, explained that Cuba has domestically developed and produced vaccines to treat a variety of ailments, including meningitis, diphtheria, tetanus, pertussis, hepatitis B and haemophilus influenzae type B.[vii] He emphasized that Cuban ‘vaccines have international prestige, made evident by the fact that hundreds of millions of doses manufactured on the island have been supplied to more than 40 nations.’[viii] In fact, Cuba was the first nation in Latin America and the Caribbean to bring a COVID-19 vaccine to clinical trials, having developed two potential candidates, SOBERANA 1 and SOBERANA 2. If either of these vaccines are determined to be safe and effective, then Cuba could become a major supplier for many of its neighbours. In discussing Cuba’s efforts to rapidly develop its own vaccine by mobilizing its best scientists and lab technicians, Doctor Eduardo Martínez Díaz stated: ‘We have worked hard, in unity, with intelligence, and we are going to do our duty, which means fulfilling our duty to the people, to Fidel and Raul.’[ix]
The Cuban health care system has faced considerable hardship, largely due to persistent material shortages on account of the American trade embargo, which has been described as ‘an attempt to kill’ Cubans through ‘hunger and disease, in order to destroy’ the Socialist Revolution. The United States has made numerous attempts to undermine Cuba’s Socialist revolution, beginning almost immediately after it succeeded in toppling the Fulgencio Batista dictatorship. In addition to economic and political sanctions, the US has employed anti-Cuban propaganda, sabotage, and terrorism, including chemical and biological warfare. Nonetheless, the vision of Fidel Castro and the determined efforts of the Cuban people have made the dream of achieving excellence in health care for the benefit and well-being of all citizens of the country into a reality. Ultimately, the destructive American economic embargo has forced Cubans to learn how ‘to do a lot with very little,’ as evidenced by their successes in terms of raising life expectancy and lowering child mortality (Fidel Castro Caracas, 1999).
The destructive impacts of the blockade were intensified in an unprecedented manner with the activation of Title III of the Helms-Burton Act in 2019. More precisely, ‘between 2019 and 2020 alone more than 130 measures’ were imposed against Cuba, ‘with the deliberate purpose of stifling the economy, creating discontent and despair in the population.’[x] These measures resulted in the cancellation of significant commercial operations and foreign investment projects in Cuba. In particular, concerns about being subjected to fines, sanctions, and legal proceedings has led many banks and financial institutions to limit their activities and services in Cuba, while a number of shipping and delivery companies have suspended many of their shipments to the island.
Recently, Cuba was even prevented from receiving a donation of medical supplies from the Chinese company Alibaba that included mechanical ventilators, COVID-19 testing kits, face masks and various other items. The considerable challenges imposed on the lives of the Cuban people by the US blockade over last six decades, including the recent intensification by the Trump administration, makes the effectiveness and achievements of its healthcare system even more impressive. This is particularly true when considering its success in terms of managing its COVID-19 outbreak and comparing it to the outcomes observed in some of its free-market oriented counterparts.
Since the COVID-19 outbreak began, Cuba has reported 7,879 cases and 132 deaths with a population of 11.34 million. That translates into about 1.16 deaths per 100,000 inhabitants, much lower than Canada’s 30.47 deaths per 100,000, and the US with 80.29 deaths per 100,000 inhabitants. In fact, New York City alone reported around 301,000 cases and 24,218 deaths with a population of 8.399 million, which amounts to a staggering 288.34 deaths per 100,000 inhabitants. Meanwhile, Brazil fared slightly worse than the US as a whole, with 80.89 deaths per 100,000 inhabitants, which might be fitting given the spectacle that Jair Bolsonaro made by publicly demanding changes to The More Doctors program (Programa Mais Médicos), a Brazilian government initiative designed to provide doctors to underserved areas of the country. Since the program was established by the government of Dilma Rousseff in 2013, approximately 20,000 Cuban health professionals have served in Brazil, including in 700 municipal districts that never had a resident doctor before.[xi]
Recently, President Miguel Mario Díaz-Canel underscored Cuba’s success in its handling of the COVID-19 outbreak by pointing out that ‘across the planet, 75% of the sick have recovered, in the Americas 65%, and in Cuba 91%.’[xii] He also stated that ‘the percentage of active cases as compared to the population in Cuba is seven, while in the world it stands at 21.8% and in Latin America, over 31.4%.’[xiii] Furthermore, ‘there have been no deaths of children, pregnant women or health personnel’[xiv] attributed to COVID-19 on the island. President Díaz-Canel also highlighted the fact that Cuban ‘intensive care units never collapsed’ even though ‘100% of confirmed cases and their contacts have been treated in hospitals.’[xv] Subsequently, they were allowed to go home after they tested negative.
A key factor in the successful handling of the COVID-19 outbreak on the island was the quick and decisive action of Cuba’s socialist government. Like many countries, Cuba closed its borders, businesses and schools shortly after the World Health Organization declared that the global COVID-19 outbreak was a pandemic on March 11, 2020. The government also made face masks mandatory almost immediately. Another important action taken by the government, which is beyond the scope of many other countries, was to deploy doctors, nurses and medical students to all streets and homes throughout the country to check for symptoms.
On a recent visit to Cuba, I had the opportunity to personally observe and experience some of the new measures and rules implemented by the socialist government aimed at protecting the lives of visitors to the island by minimizing the risk of contracting the COVID-19 virus. At the Cuban airport, passengers were put into a line outside of the main entrance as soon as they disembarked the airplane, with Cuban officials ensuring that the 2-metre distancing rule was being respected. Inside, a team of workers disinfected all carry-on baggage and purses, while passengers were made to sanitize their hands. Subsequently, a team of medical professionals checked each passenger’s temperature before collecting samples that were labelled and sent to a lab for testing. Meanwhile, a large contingent of workers were busy continuously cleaning every single area of the airport, as well as any objects that that passengers might have touched or otherwise come in contact with. This was a stark contrast with the airport experience when I returned to Canada, as social distancing was not enforced while waiting in lines, carry-on baggage was not disinfected, no medical personnel were visible, and no mandatory COVID-19 tests were administered.[xvi] Compared to the experience in Cuba, the Canadian airport appeared to be very poorly organized and lacking in resources when it comes to encouraging rigorous and effective hygiene practices, and enforcing social distancing rules.
At the Cuban resorts, employees are regularly tested. There are also nurses and doctors on staff to monitor the health of all their clients, which includes taking everyone’s temperate each morning. Furthermore, all public areas have been organized in a manner that ensures public distancing, while washrooms, tables, chairs, and other items are sanitized immediately after being used by tourists.
Broadly speaking, Cuba’s success in terms of containing its COVID-19 outbreak is due in large part to the centrally planned system’s adherence to the principle that free and universal health care is a fundamental human right. Consequently, its leaders have consistently made extensive investments in health care services since the early days of the Revolution. In addition to providing medical care to all inhabitants of the island, Cuban doctors are renowned for venturing well beyond their borders en masse in order to assist other nations in need, particularly in their most remote areas that are underserved and often have no doctors at all. None of this is particularly surprising, as the Cuban government has committed itself to building ‘awareness,’ and instilling ‘feelings of solidarity and a generous internationalist spirit’ at its medical schools since triumph of the Revolution (Fidel Castro Caracas, 1999).
For Cuban medical workers, their ‘mission is to create a doctrine about human health, to set an example of what can be done in this field’ (Fidel Castrol Havana, 1999).[xvii] Since the Revolution, over 400,000 Cuban health professionals have been sent to 164 countries around the world to help them meet their health care needs, and to provide assistance in times of crisis and in the aftermath of natural disasters.[xviii] Moreover, Cuban medical workers will often remain in foreign countries in order to assist them in the development of their own health care systems and services. Recently, Cuba sent about 4,000 health workers to around 40 countries to help them with their COVID-19 outbreaks.[xix]
Additionally, Cuba helps combat doctor shortages in developing countries by providing free medical school to students from those regions. In fact, Havana’s Latin American Medical School (Escuela Latinoamericana de Medicina (ELAM)) is ‘the largest medical school in the world.’[xx] ‘The University of Toronto has 850 medical students and Harvard University has 735. ELAM has twelve times more students than those two schools combined: 19,550.’ In 2002, Fidel Castro delivered a speech to students of the Latin American Medical School in the presence of former U.S. President Jimmy Carter and stated:
what good would it do if you all went back to your countries to become part of institutions where, sadly, financial concerns, commercialism and selfishness prevail? What good would it do if no one was willing to go work in the mountains, the plains, the remote corners of the countryside or marginal neighborhoods of the cities to practice the noble profession of medicine? More than a medical school, our most fervent hope is that this will be a school of solidarity, brotherhood and justice.[xxi]
During a 2003 visit to Buenos Aires, Argentina, Fidel Castro underscored Cuba’s commitment to preserving human life when he said:
Our country does not drop bombs on other countries, or send thousands of planes to bomb cities; our country has neither nuclear weapons, nor chemical weapons, nor biological weapons. The tens of thousands of scientists and doctors in our country have been educated in the philosophy of saving lives. It would be totally contradictory to their formation to ask a scientist or a doctor to work producing substances, bacteria or viruses capable of causing the death of other human beings…Tens of thousands of Cuban doctors have offered their services on internationalist missions in the most remote and inhospitable places on the planet. I once said that our country could not and would not ever launch preemptive attacks against any dark corner of the world. On the other hand, our country has sent badly needed doctors to the darkest corners of the world. Doctors and not bombs, doctors and not intelligent weapons…[xxii]
Fidel Castro (Havana 1998) believed that, instead of investing massively in the development of weapons to kill in the most efficient and destructive ways imaginable, countries with ‘the resources for it should promote medical research and put the fruits of science at the service of humanity, creating instruments of health and life and not of death.’ He was very proud of the Cuban health care system’s accomplishments, both domestically and internationally, and trusted that Cuban doctors had the integrity and skills necessary in order to save lives anywhere in the world.
Fidel Castro would likely have not been surprised by the failure of health care systems to adequately respond to and manage COVID-19 outbreaks in many of the countries that subscribe to capitalism. He was highly critical of the practice of treating health care services as though they were business transactions in a free-market place. Instead, he often reiterated the point that the commercialization of health care was ‘repugnant,’ and everybody should have free access to adequate health care services. Accordingly, the privatisation of health care would not be permitted on the socialist island nation of Cuba. In addition to denouncing all forms of private health care, Fidel also strongly condemned profit-oriented pharmaceutical companies. He specifically expressed his frustration with large and powerful pharmaceutical companies that dedicate themselves to maximizing their profits instead of demonstrating a genuine commitment to human life when he addressed ‘the special session commemorating the 50th anniversary of the World health Organization,’ in Geneva, Switzerland on May 14, 1998, when he stated:
medicines, that should be made to save lives, are sold at increasingly higher prices. In 1995, the market of pharmaceuticals involved 280 billion dollars. The developed countries with 824 million people, 14.6 percent of the world population, consume 82 percent of the medicines while consumption in the rest of the world with a 4,815 million population is only 18 percent. The prices are actually prohibitive for the Third World where consumption is limited to the privileged sectors. The control of patents and markets by the big transnational companies allows them to raise prices over ten times above production costs. The market price of some advanced antibiotics is 50 times higher than their cost.[xxiii]
Fidel Castro was not only critical of the profit maximizing behaviour of large pharmaceutical companies, he also frequently spoke of the failure of governments to provide adequate public health care services for their citizens. In a 1998 speech in Havana, he claimed that public hospitals in many countries failed ‘because they didn’t have resources, because they didn’t have a budget.’ He recalled that public health care was in a similar state in Cuba prior to the Revolution as, ‘in addition to scarce and diminishing budgets, a part of these budgets was misappropriated’ (Fidel Castro Havana, 1998). He was always a strong advocate of publicly funded and managed healthcare systems, as he stated that ‘If the state is sick, let’s cure the state, let’s give the state health. It’s necessary for the state to function healthily. But let’s not hand the solution of problems of human health over to the market’[xxiv] (Fidel Castro Havana, 1998). Fidel Castro believed that if a state was truly committed to the achievement of the collective good, it would find a way to provide its citizens with universal health care services even in the face of economic difficulties and other problems. This is evidenced by Cuba, as Castro stated:
We have lived the experience and we’ve had the opportunity, with very few resources, to see how public medicine can work and, even today, with a double blockade, it could be said, it works, not with all the resources that we would like, but, for many years, the country invested in hospitals. It first used those that existed and it later built many new hospitals and it built clinics, modest hospitals, including in the mountains, in the countryside, with a network of hospitals and polyclinics being established throughout the country, even managing to create, in addition, that outstanding network for primary care that is now made up of our family doctors, with a new sense.[xxv]
In a 1998 speech in Havana, Fidel Castro underscored the critical importance of family doctors in Cuba, as he explained that:
every doctor that graduates, except in a very few specialties, in order to become a specialist in the varied branches of medicine, first has to be a family doctor, a professional with great knowledge of man, experience, human behavior, who has looked after patients in a community, to know well how they live, in what social conditions. Then, later, if they want, they can acquire a second specialty…But they’re people who already have very wide knowledge. They’ve studied for six years at university and they’ve studied for three years from their office. They’ve had nine years studying and, later, they’ll have to study for another three or four years if they’re going to acquire a second specialty.[xxvi]
According to Fidel Castro, the success of the family doctors system in Cuba could not have been achieved under the auspices of the private sector. While he acknowledged that a number of other nations around the world also utilized family doctors, he pointed out that they often live far away from their patients. To the contrary, family doctors on the socialist island live close to their patients, sometimes right next door. ‘They can be 100 meters from the resident, from the citizen. Others have the doctor 50 meters away if they live nearer the doctor’s office. In the cities, the residents…live with a doctor next door.’[xxvii] Family doctors can essentially be found everywhere in Cuba, including in the nurseries, schools, factories, hotels and resorts, and many other workplaces. Fidel Castro (1999 Havana) made it clear that there could never be enough doctors, stating that Cubans are not ‘afraid of the number of doctors. There will never be too many doctors anywhere, be it a passenger’s plane, a train or a boat.’ [xxviii] In a 1999 speech to students graduating from the Havana Higher Institute of Medical Sciences, Fidel Castro explained that when it was suggested to him that Cuba would not need any more doctors after the island achieved the milestone of 20,000, he responded by saying:
You think that there will be too many doctors? That is not possible…because doctors have to defend people’s health like the CDRs [Comités de Defensa de la Revolución] defend the Revolution; there should be one on every block.[xxix]
Before Socialist Cuba established its health care system, people were often forced to wait for days, or even weeks, in order to have simple health procedures performed at hospitals. Now that family doctors with adequate knowledge and training to diagnose and treat many diseases, illnesses and other health problems are available all over the country, people have the option of avoiding hospitals for relatively minor health issues. However, they can also see a specialist at a polyclinic or hospital if that is their preference. Fidel Castro believed that providing people with such a wide range of choices when it comes to health care is an effective approach for the ‘saving of beds and facilities.’[xxx] It appears that he was correct, as Cuban emergency rooms and hospitals never have to contend with overcrowding. This was particularly evident during the current pandemic, as Cuban emergency rooms were at no point at risk of being overwhelmed, unlike those of a number of capitalist countries.
Cuba’s successful handling of the COVID-19 outbreak relative to many capitalist countries is not overly surprising, given that Cubans have considered health to be a fundamental human right since the Socialist Revolution. This has led the country to make significant investments and expend a massive collective effort in establishing free health care services for all Cubans. However, other features of the socialist regime were also instrumental in successfully combatting the spread of COVID-19 in addition to Cuba’s commitment to universal healthcare. For instance, President Díaz-Canel explained that Cuba’s centrally planned system, one of the fundamental and most criticized aspects of its socialist regime, played an important role by ensuring the availability of basic food items, cleaning supplies, and personal hygiene products since the outbreak began. History has shown that Cuba’s socialist government has always been very capable of swiftly and effectively mobilising its economic, natural and human resources in order to secure the well-being and safety of its citizens when faced with a catastrophic event. In fact, president Díaz-Canel went so far as to describe Cuba’s successful handing of its COVID-19 outbreak as ‘almost a miracle,’ which is an outcome of ‘people, experiences, principles and the thinking of Fidel and Army General Raul Castro Ruz.’[xxxi] He further elaborated that ‘those of us who are members of the band of non-conformists and optimists, like Fidel and Raúl, learned with them and their comrades in struggle that all challenges can be overcome. Cubans are proving, once again, that it can be done.’[xxxii] He also highlighted the key roles of solidarity, collective efforts, dedication and sacrifices on the part of Cubans since the outbreak began.[xxxiii] On October 28, 2020, president Díaz-Canel delivered a speech in ‘closing the Fifth Ordinary Period of Sessions of the National Assembly of People’s Power,’ in which he stated:
There is a component in Cuban DNA, in the magnificent mix of ethnicities and history of continuous resilience, from which emerges from “that sweet word: Cuban.” But there is another factor that is no less important, which is the conscious construction, over more than 60 years, of a work that is larger and stronger than we are, with an authentic leadership, respected and admired in the world, more respected and admired the more it has resisted the blows of the adversary without giving up. I speak, of course, of Fidel, of Raúl, of the Centennial Generation, whom we are honored to follow, with proud dedication to the cause to which they devoted their lives.[xxxiv]
Socialist Cuba has always strived to achieve a more humane and just world order, characterized by solidarity and social cooperation among human beings. Accordingly, its leaders and supporters of the Revolution were acutely aware of the many defects and destructive outcomes of free-market capitalism. In fact, some of the key factors that contributed to COVID-19 being so disastrous on a global level include the poverty of neo-liberal governmental policies, the inflexibility of neo-liberal economists, and the myopic visions of politicians who never cared about the collective good. However, the panic that ensued during the pandemic led many Western governments to suddenly transition to central deliberate planning, after being devoted to free-market capitalism, while also being adamantly opposed government interventions at achieving the collective good, for decades. By essentially transitioning away from the laissez-faire approach and towards central planning, traditionally free-market oriented governments have temporarily abandoned the principles, policies and behaviours that they have adhered to and promoted for the last four decades. In fact, the extent to which these governments have recently involved themselves in the economy, as well as in people’s lives, represents unchartered waters for many of them. Ultimately, the failures of Western countries in dealing with their respective COVID-19 outbreak supports Fidel Castro’s contention that free market capitalism is ill-equipped when it comes to responding to catastrophic events. In this regard, he stated that ‘the state is sick’ and needs to be cured. However, curing the state from the ills of capitalism is not something that can be achieved swiftly or easily.
According to Fidel Castro (Havana 1998), only revolutionary people could dedicate themselves to ensuring that the interests of the masses are ‘aligned with the best causes of humanity,’ which is necessary in order to achieve a more humane and just world order. Furthermore, he believed that ‘the Revolution is not just about putting forward ideas, it is about carrying out ideas. The Revolution is not theory; it is action, above all’ (Fidel Castro Havana, 2002). Cuba has shown that ‘whatever the Revolution has proposed to do, it has achieved. Whatever the Revolution has begun, it has carried on with. And this is the result of ideas turned into reality, of tasks undertaken and carried out’ (Fidel Castro Havana, 2002).
‘Long live free Cuba! Long live the victorious Revolution!’ (Fidel Castro)
[vi] ‘BioCubaFarma, the Cuban organization of Biotechnology and Pharmaceutical Industries, manages the country’s efforts toward manufacturing medicines, diagnostics and medical equipment and providing high quality life science services to improve people’s health. BioCubaFarma serves as a gateway for potential partners and investors interested in accessing the extensive biopharma resources Cuba has to offer.’ https://www.nature.com/articles/d43747-020-00522-5
[xi] In the first four years of The More Doctors program, the percentage of Brazilians receiving primary health care rose from 59.6% to 70%. Nonetheless, Bolsonaro stated that the 11,420 Cuban doctors working in poor and remote parts of Brazil could only stay if they received 100% of their pay and their families were permitted join them. He also questioned the qualifications of the Cuban doctors and suggested that they might have to renew their licenses in Brazil. In response, Cuba’s health ministry announced its withdrawal from the program, stating that ‘these conditions make it impossible to maintain the presence of Cuban professionals in the program.’ The abrupt withdrawal of Cuban doctors has not only adversely affected Brazil’s healthcare system, with Bolsonaro failing to deliver on promises to quickly find domestic substitutes, it has also hurt Cuba’s economy.
[xvi] Additionally, the kiosk display screens that each passenger has to use to fill out their Canada Border Services Agency Declaration (CBSAD) forms were not disinfected after each use. There is also a new COVID-19 form to fill out, which is done at those same kiosks using a couple of pens that have been left there for passengers to share without being disinfected. After getting through customs, the Canadian airport did not demonstrate the same level of commitment to sanitizing the washrooms and other public areas as the one in Cuba, where personnel were observed engaging in frequent cleaning.
Dr. Birsen Filip holds a Ph.D. in philosophy from the University of Ottawa.
Tags: COVID-19, Coronavirus, Cuba, Latin America Caribbean, Pandemic
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