Healthcare System and Pharmaceutical and Biotechnological Industries in Cuba: Or How a Socialist Revolution Can Materialize–Part II

Cuba’s Internationalist Solidarity in Health

In 76 countries around the world, Cuba’s internationalist solidarity in health is currently reflected in the presence of more than 50,000 professionals, approximately 50% of whom are physicians—more than half of whom are women (MINSAP, 2021). ¹ Its goal is not to disseminate a political doctrine or exert diplomatic pressure, much less to open markets or make profits; it is to concretely and rapidly improve the health and quality of life of the populations being helped, as well as the social conditions for the development of their countries, while affirming ethical principles and applying humanist values through, and in the practice of, medicine. The teams are sent to locations where there is neither health infrastructure nor local physicians, most often to remote and difficult-to-access places. Consultations and medical procedures are all completely free for patients in host countries, where, generally, a private system requires sick people to be insured in order to receive treatment—which is the opposite of the Cuban approach.

Doctors on assignment abroad have their living expenses (food and lodging) covered by the Cuban state and earn remuneration on average 5–10 times that of those on the island. However, this represents only a portion (between a quarter and a third) of the sums paid by host governments to the Cuban state budget, which, then, funds medical missions to poor countries in the South and the improvement of the National Health System in Cuba. Upon their return, internationalist doctors can be offered an apartment and household appliances.

After the victory of the Revolution in 1959, Cuba wasted no time in offering its health assistance through missions abroad, regardless of the political leanings of the governments of the countries receiving help. Therefore, in May 1960, the very first emergency medical brigade was provided to earthquake-stricken Chile, even though at the time this country’s president was hostile to the Cuban Revolution. Between May 1963 and July 1965, the first so-called “permanent” brigade, composed of 30 doctors, 4 dentists and 14 volunteer nurses, was sent to Algeria. Since then, teams, bringing tons of medicine with them, have provided emergency assistance in various countries affected by natural disasters or epidemics: Peru (1970), Nicaragua (1972), Honduras (1974), Mexico (1985), Armenia (1988), Iran (1990), etc.

When Hurricane Mitch devastated Central America in October 1998, Cuba came to the aid of the populations of the three most affected countries—Guatemala, Honduras, and Nicaragua—and decided the following month to implement a comprehensive health program in the region, then gradually expand it to countries in South America, Africa, Asia, and Oceania. In 1999, following severe flooding in Venezuela, 447 Cuban professionals left to help the victims, foreshadowing future medical missions to that country. At the Millennium Summit in 2000, Cuba declared that it would make available to the World Health Organization (WHO) the necessary personnel for a large-scale plan to combat HIV/AIDS in Africa. This initiative led to the opening of medical services in several countries where Cuban and African doctors work together. Between 2000 and 2003, other medical teams fought dengue epidemics in Nicaragua, Honduras, El Salvador, and Ecuador. In 2005, 688 Cubans intervened in Guatemala, which had been devastated by Hurricane Stan.

This same year, 2005, marked a new turning point. After Hurricane Katrina hit the United States in August, the Cuban government established the Henry Reeve Contingent, composed of brigades of personnel that could be mobilized within 24–48 hours and specialized in providing health humanitarian aid to victims of natural disasters and epidemics abroad. Despite the political dispute between them, Cuba offered to make its doctors available to the United States—a proposal that went unanswered. Since the creation of this Contingent, more than 88 brigades have operated in 56 countries. Their staff exceeds 10,000 health professionals, all volunteers and generally highly experienced. After the October 2005 earthquakes in Pakistan, 2,564 of them treated nearly 2 million victims for 8 months in the 32 field hospitals set up by the Cubans, then donated to local health authorities. Indonesia and Sri Lanka, hit by a tsunami, also received brigades that same year.

By the beginning of the 2020s, 24 countries had signed a comprehensive health program agreement with Cuba: Belize, Burkina Faso, Chad, Congo, Dominica, Eritrea, Eswatini, Ethiopia, Gambia, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Jamaica, Kiribati, Lesotho, Mozambique, Niger, Saint Vincent and the Grenadines, Sao Tome and Principe, Tanzania, Trinidad and Tobago, and Zimbabwe—plus the Sahrawi Republic. In these cases, assistance focuses on primary care and is supplemented by specific measures designed, in particular, to reduce infant mortality or to combat HIV. In addition, 41 other countries host Cuban doctors on permanent missions (teams remaining in the country for two or three years before being relieved), including: Algeria, Angola, Azerbaijan, Bahrain, Botswana, China, the Dominican Republic, Equatorial Guinea, Gabon, Ghana, Grenada, Kenya, Kuwait, Mauritania, Mexico, Namibia, Panama, Qatar, Saudi Arabia, South Africa, Suriname, Timor-Leste, Uganda, the United Arab Emirates, Uruguay, Vietnam, and others.

In 2010, Cuban doctors responded to the cholera epidemic in Haiti, where they provided care to nearly 400,000 people. During 2014, Cuba carried out a malaria vaccination campaign in 15 African countries. In September of that same year, Cuban authorities announced their willingness to participate in the WHO-coordinated operation to combat Ebola in West Africa. On the island, over the course of 10 days, some 5,000 doctors and nurses volunteered for this highly dangerous mission; 500 received special training; ultimately, 265 were selected and went effectively to fight the epidemic, with the first group from the Henry Reeve Contingent arriving in Sierra Leone, followed by two others in Liberia and Guinea. It was the only mission in the world to provide physically direct assistance to infected people. The Cubans treated more than 2,000 patients. One member of the Contingent contracted the Ebola virus and later recovered; but, unfortunately, two others died of malaria.

In April 2003, the Venezuelan government of Hugo Chávez launched the Barrio Adentro mission (that is, “mission inside the neighborhood”), a comprehensive general medicine plan designed to provide diversified and free health services to the local population by sending more than 20,000 Cuban doctors. This resulted in the opening of “people’s hospitals,” city by city, and of dispensaries for the most urgent care, neighborhood by neighborhood, thus making care accessible to all. This device also incorporated pediatric, dental, and ophthalmology centers, as well as analysis laboratories, installed within the communities and also free of charge. Today, this mission has approximately 1,600 health units throughout the country, meeting the primary or complex health needs of the Venezuelan population. This social pattern was complemented by: Barrio Adentro 2, in June 2005, which offered citizens free diagnostic, high-tech care, and rehabilitation centers; Barrio Adentro 3, in August 2005, which expanded the hospital network, primarily in medical deserts; and Barrio Adentro 4, in August 2006, which opened specialized hospitals (such as in pediatric cardiovascular surgery). In addition, Barrio Adentro Deportivo aims to increase physical exercise in local communities through the work of more than 5,000 Cuban sports instructors and the teaching of original practices: prophylactic physical activity, workplace gymnastics, recreational aerobics called “dance therapy,” etc.

Starting in July 2004, as part of the Bolivarian Alliance for the Peoples of Our America, Cuba launched the Milagro mission (or “miracle mission”), a vast campaign to provide free surgery to people suffering from cataracts or other eye diseases who were unable to finance these operations, which are very expensive in their own countries. The first patients arrived in Cuba in July 2005 from Venezuela. Some 50 health centers were subsequently opened in Latin American and Caribbean countries, before the mission was extended to Africa and Asia in September of that same year. Since then, more than four million patients from 35 countries have been treated by Cuban doctors.

Cuban assistance has also taken the form of the creation of medical schools abroad, operating thanks to the presence of Cuban personnel on the ground. This was the case in South Yemen (1976), Guyana (1984), Ethiopia (1984), Guinea-Bissau (1986), Uganda (1988), Ghana (1991), Angola (1992), Gambia (2000), Equatorial Guinea (2000), Haiti (2001), and Eritrea (2003). This educational cooperation involved nearly 230,000 foreign medical students, but more than half a million people in total benefited from medical training provided by Cubans in the countries of the South. In 2006, Cuba also launched a program for the Caribbean through the Dominica School of Nursing, as well as other similar centers in countries of the Caribbean Community.

As early as November 1998, the Latin American School of Medicine (ELAM) opened in Havana in order to offer six-year medical science training to young foreigners from disadvantaged families or discriminated minorities who could not afford such a program in their own countries. Tuition fees are covered by higher education scholarships awarded by the Cuban government, including for the specialization years. Recently, students have been helping to finance these studies through scholarships awarded by their home countries. Equipped with modern auditoriums and laboratories, the ELAM began its programs in February 1999. The first class of 1,610 students, coming from 18 countries, graduated in August 2005. Upon entering the school, students receive a premedical refresher course and, for non-Spanish speakers, Spanish lessons. Sciences are taught for the first two years on the Havana campus, before students are distributed to faculties across the island to pursue clinical studies, then complete their internship in the sixth year and take their doctoral exam. The only requirement for students is that they agree, once graduated, to return to practice in poor neighborhoods or communities in need of healthcare facilities in their home countries. There are currently 11,000 students enrolled at the ELAM, from which nearly 40,000 doctors have graduated since its creation, mostly general practitioners, and almost all with a doctorate. This concerns more than 140 countries, mainly Latin American and African, but US students (mostly African-American or Hispanic) are also there.

The generosity and selflessness that drive the Cuban vision of health, driven by the political will of a government and the moral conscience of a people who place virtue before profit, despite extremely constrained public budgets, can be illustrated by an example. In 1990, Cuba decided to admit more than 26,000 Ukrainian children aged 5–15 who were victims of the Chernobyl nuclear disaster. Suffering from cancers and/or malformations caused by radiation, they were treated at the Tarará Children’s Hospital in Havana—free of charge, it should be noted. Those who required more prolonged care were able to continue to receive treatment—still free of charge—even when, after the end of the USSR, Ukraine’s new leaders sided with the United States.

The COVID-19 Pandemic: Health Measures, Vaccines Discovered, and Medical Missions

The scale and coherence of Cuba’s National Healthcare System enabled the island to respond to the COVID-19 pandemic in a relatively more humane and effective manner than many other countries. As early as January 2020, the Ministry of Public Health (MINSAP) had developed an anti-COVID-19 plan, in conjunction with the civil defense system. ² The information and communication policy aimed at the Cuban population was characterized by competence and transparency. Cuba’s health response was fundamentally based on the joint efforts of, on the one hand, family doctors and nurses, hospital staff, and medical students, supported by a popular mobilization in solidarity, and, on the other hand, research teams from the pharmaceutical and biotechnological industries.

The first cases of infection on the island were recorded on March 11, 2020, among tourists carrying the virus and immediately treated at the Pedro Kourí Institute of Tropical Medicine (IPK). Implemented nationwide starting March 17, the intersectoral plan against COVID-19 included epidemiological surveillance aimed at detecting cases of contamination as quickly as possible using PCR tests to diagnose the SARS-CoV-2 virus that causes COVID-19—tests being carried out even on asymptomatic individuals. Masks were required in public places, physical distancing was recommended, and hygiene was reinforced. More than 28,000 medical students were deployed across the country to conduct regular door-to-door visits, reaching nearly 4 million people daily. Contact cases were closely monitored and positive patients were, if necessary, immediately treated in hospitals or various accredited healthcare centers. Once recovered, those who tested positive were required to remain in isolation at home for an additional 14 days, under medical supervision. In schools, in-person classes were suspended, with classes moving to remote teaching. Public events were canceled. On March 25, 2020, commercial air travel was suspended. Borders were closed, and health screenings were implemented at the country’s airports and ports, with a 14-day quarantine for all travelers entering Cuba, whether Cuban citizens or foreign visitors. Across the island, public transportation was shut down, and retail outlets selling basic necessities were decentralized. From April 9, 2020, the date of the indigenous transmission phase of the virus, the health authorities finally decided to restrict the population’s movements to what was strictly necessary—and, in areas where the virus was openly circulating to confine. The pandemic peaked relatively late, in July 2021, with an average of 9,000 cases of infection and 70 deaths per day, before the curve of contaminations began to decline.

The Cuban pharmaceutical and biotechnological industries played a key role in the strategy to combat the pandemic, thanks to the protocols established by the MINSAP, which, in the vast majority of cases, used drugs or vaccines developed on the island. Such medications have proven effective in severely ill patients and/or at-risk groups. The prophylactic device involved the nasal administration of recombinant human interferon alpha-2B produced by the Center for Genetic Engineering and Biotechnology (CIGB), Nasalferon, stimulating immune responses at the mucosal and systemic levels. Therapeutic treatments applied to sick people included domestic medicines, such as Itolizumab, a monoclonal antibody developed by the Center for Molecular Immunology (CIM), Peptido CIGB 258, an immunomodulatory peptide with anti-inflammatory properties, Jusvinza, which is commonly used to treat rheumatoid arthritis or autoimmune diseases, Heberferón R, an interferon alpha-2B, and Biomodulin T, an immunomodulator. Other products under study included the CIGB 300 peptide, the CIGB 2020 vaccine, and VAMENGO-BC, notably. Furthermore, during this period, the Biotechnology and Pharmaceutical Industries Group BioCubaFarma launched around 15 new projects for drugs, treatments, and methods aimed at preventing and combating COVID-19.

Vaccine research began early and resulted in the development of five candidates (Soberana 01, Soberana 02, Soberana Plus, Abdalá, and Mambisa), with the two most effective (in this case, Soberana 02 and Abdalá) ultimately being widely administered. On July 9, 2021, the Center for State Quality Control of Medicines, Equipment, and Medical Devices authorized the emergency use of a first COVID-19 vaccine, that is, CIGB-66 or Abdalá, designed by CIGB, under the auspices of MINSAP—the first discovered in Latin America. On August 20, the same authority gave the green light for the use of a second vaccine, FINLAY-FR-2 or Soberana 02, produced by the Finlay Vaccine Institute (IFV), under the supervision of the Ministry of Science, Technology, and the Environment (CITMA).

The quality controls of the CIGB-66 vaccine candidate, strictly adhering to local site inspection requirements (especially those of the Aica Laboratories where it is produced) and international standards, ensured that it was suitable for use in humans. Preliminary studies to test its safety had proven that it did not induce adverse reactions, and made it possible to define the number, frequency, interval and route of administration of doses. Phase I of clinical trials began in December 2020 on 132 volunteers aged 19 to 54 years. With the immunogenicity and safety of the candidate established, Phase II broadened the age range to 80 years on 660 other subjects. In June 2021, the results of Phase III, this time carried out on nearly 50,000 volunteers, demonstrated that Abdalá had an efficacy of 92%, much higher than the 50% required by the WHO for anti-COVID-19 vaccine candidates.

As early as August 2020, after the encouraging results of Soberana 01, the IFV announced work on another candidate, Soberana 02. Its Phase I clinical trials began in October 2020 on 80 volunteers. Phase II continued 2 months later and demonstrated maximum immunity reached after 14 days. Phase III, spread from March to June 2021, was carried out with 45,000 volunteers aged 19–80 receiving two doses, with an additional booster of the Soberana Plus vaccine. The studies were also conducted on groups aged between 2 and 18 or those with specific risks. Across all trials, the efficacy of the three doses exceeded 91%.

Based on these satisfactory findings, a general vaccination campaign was launched across the country. By May 2021, health authorities were able to vaccinate 1.7 million residents in Havana, with priority given to healthcare workers on the front lines of the pandemic. Thus, before the end of 2021, more than 87% of the Cuban population had received a complete immunization schedule, either by family doctors or nurses, or in vaccination centers. As of February 20, 2022, 8,487 deaths from COVID-19 had been recorded in Cuba, out of the 1,065,385 confirmed cases observed on that date since the virus first appeared on the island. It is, therefore, possible to argue that the pandemic has been kept relatively under control there, with local infection and case fatality rates among the lowest in the world.

Several foreign research centers have been involved in the final phases of clinical trials for Cuban vaccine candidates. For example, in 2021, the Pasteur Institute of Iran in Tehran received 100,000 doses of Soberana 02, and 60,000 doses of Abdalá and Soberana 02 were sent to Venezuelan laboratories, in order to confirm their efficacy. Vaccine manufacturing sites in Cuba quickly had to increase their production capacity to meet demands from foreign health authorities, not only from Iran and Venezuela but also from Vietnam, India, Pakistan, and Argentina, among others, who expressed a desire to import them. Belarus was the first European country to register Soberana 02.

Through export agreements, some 50 countries have purchased recombinant interferon alfa-2B from CIGB. As early as 2020, the Chinese Health Commission selected this antiviral for inclusion in its anti-COVID-19 protocols. A collaboration between the Beijing Institute of Technology and the Center for Immuno-Trials (CIE) created a platform for using immunological and molecular biology techniques to rapidly detect the SARS-CoV-2 virus. Besides, the Pancorona vaccine against COVID-19 emerged from a Sino-Cuban laboratory located in Yongzhou, Hunan Province, southern China.

During the pandemic, Cuba also provided assistance to many foreign countries, including those in the North. With the arrival of doctors and nurses in Italy (52 in Lombardy in March 2020, 60 in Sicily in November of the same year, and another 51 in Calabria in early 2023), Cubans were conducting health missions in a Western European country for the first time. In mid-2020, the Cuban government responded favorably to a request from France, whose need for medical personnel in its overseas territories had become acute. During this difficult period, brigades of the Henry Reeve Contingent, composed of more than 2,600 professionals—in addition to 28,000 doctors already present in 59 countries at the time of the pandemic’s outbreak—were sent to fight COVID-19 in more than 40 countries, including Cape Verde, Togo, South Africa, Qatar, Mexico, Belize, and Haiti (MINSAP, 2022).

The Originality of the Cuban Strategy

The primary goal of developing Cuba’s pharmaceutical and biotechnological industries is to supply the National Healthcare System established for the well-being of the people. After the fall of the USSR, Cuba found itself plunged into an international pharmaceutical market dominated by the United States, whose firms controlled a third of global production, and which, moreover, tightened the embargo against the island (we shall return to this point shortly). Under these conditions, biotechnology was confirmed by the Cuban government as one of the priority sectors for investment. Cuba built its medical research system alone, driven not only by the political will to meet the vital social needs of the population and to build national sovereignty, but also by force of circumstance, since the leap forward made by this sector was achieved independently of both the models implemented by the (Soviet) USSR and the (capitalist) United States. The aim was to produce not only effective and inexpensive medicines and vaccines but also equipment and services, therefore often adapted to the type of primary care provided by the National Health System. An additional objective was to elevate Cuba to the status of a medical power of international importance by promoting pharmaceutical chemistry and new biotechnologies as elements of the country’s development strategy and as engines of sustainable socioeconomic growth, boosting high-tech exports and sharing the fruits of its scientific and technological discoveries with the rest of the world (Álvarez & Máttar, 2004; Ferriol Muruaga, 1998).

Cuba’s pharmaceutical and biotechnological industries operate quite differently from those, capitalist in nature, that currently predominate globally. This sector, made up of two distinct components—on the one hand, the pharmaceutical industry, whose products derive primarily from synthetic chemistry, and, on the other, biotechnologies, which work on living organisms or their components and whose research is much riskier—presents internationally similar characteristics for all the players involved. Indeed, this is a highly complex sector that faces specific challenges: Technological progress is rapid, product life cycles are shortening, competition is intensifying between private oligopolies, average research costs are rising, regulations are becoming increasingly strict and differ from country to country, and the share of biotechnologies is increasing in the production of new drugs (combination vaccines, recombinant proteins, monoclonal antibodies, gene therapies, etc.), which is transforming the pharmaceutical industry and requiring ever more time and capital. ³

Nevertheless, Cuban units reject the modus operandi in force in today’s globalized and financialized capitalism, where the interests of “Big Pharma” shareholders prevail, with their speculative behavior that allows them to monopolize stock market profits even in the absence of actual production, their preference for privatized healthcare systems and expensive treatments for the sick, and their rapacity which leads, through overly rigid and exclusive property rights, to hindering follow-up innovation by preventing the entry of cheaper drugs onto the market, even if their distribution would have beneficial health effects for the world’s populations. The Cuban revolutionary authorities refuse the law of profit maximization, which leads to everything being subject to its logic, including the quality of care and patient health.

Cuba has chosen to subordinate economic considerations to the ultimate imperative of public health. To achieve this, the pharmaceutical and biotechnological industries are fully state-owned, and their financing comes exclusively from the state or from revenues generated by their own activities abroad. Consequently, the island demonstrates that the growth of this sector is feasible without being conditioned by the forces of the private capital market and competition motivated by privately appropriated profit, characteristics of prevailing capitalism. In the Cuban alternative system, conflicts between owners with divergent interests are avoided, cooperative decisions become possible, and exchanges between institutions are harmonized.

For many medications, the number of patients is known and demand can, thus, be anticipated, and therefore also the volumes of inputs necessary for their production. In other words, the MINSAP is able to plan the production and distribution processes of the sector taken as a whole. Integrated into the country’s development strategy planning, BioCubaFarma establishes its own plan for the next 10 to 15 years, providing for the financing methods (through export revenues, budget allocations, foreign investments, credits, etc.) for its operating and investment expenses. The creation of the Scientific Pole itself resulted from this planning.

It is this planning that makes it possible to articulate programs with rapid returns and long-term socioeconomic projects. This requires that the state ensure control over decisions relating to these industries, without privatization. The Cuban authorities certainly solicit foreign investors, but do not accept them in either the research or production phases. Foreign capital is directed toward the construction of infrastructure or factories (as in the Mariel Special Zone, located about 50 kilometers west of the capital), or toward marketing partnerships for the insertion of products into global markets. The pharmaceutical and biotechnological sector operates under a budgetary framework separate from the state-funded healthcare system and from state-owned enterprises that must contribute to public budgets. In fact, the sector is granted relative financial autonomy, allowing it to reallocate a portion of its export revenues within itself. Revenues from overseas sales of the VA-MENGOC-BC vaccine, for example, were reinvested to kick-start the Scientific Pole as a whole, and then to accelerate its growth.

The industries in question operate in an integrated, synergistic, and “full-cycle” manner. Integration consists of bringing together within the BioCubaFarma group the various entities constituting, on the one hand, the pharmaceutical sector, which generally produces well-established medications, and, on the other hand, biotechnologies, which are more complex and whose discoveries are generally more innovative. Integrating these sectors brings the advantage of being able to organize— between institutions of the same group, systematically and at the highest level—discussions on their projects, the coordination of their work, and collaborations in their research. The units operate in synergy, according to a principle of solidarity rather than rivalry. Each exchanges information on its difficulties and contributes to the collective with its strengths to create new products through ongoing cooperation.

From basic or applied research to the implementation of product or production process innovations, knowledge is shared between scientific teams, most often multidisciplinary. Efforts are made jointly. Thus, the method used throughout the product development chain deploys a complete cycle for the sequence of R&D, production, and commercialization, in a fully protected circuit linking the successive stages of (a) scientific creativity, from which innovations emerge; (b) production, where safe and effective medicines are manufactured; and (c) availability of products to professionals in the National Healthcare System or on global markets.

In Cuba’s various provinces, a spatial planning policy has led to the creation of scientific institutions bringing together research, teaching, or production centers outside of Havana or its suburbs. As a matter of fact, in the provinces of Villa Clara, Sancti Spíritus, and Ciego de Ávila, biotechnology units have been opened, particularly to meet specific regional needs. The CIE, for example, relies on a national network of nearly 170 local laboratories. As for the CIM, this has a complex production site in Santiago de Cuba (LABEX) and conducts clinical trials in various hospitals across the country’s 15 provinces. Furthermore, worker participation in the innovation movement is encouraged, notably through science and technology forums. So, the broader scientific community includes associations such as those of the Innovators and Rationalizers or of Youth Technical Brigades. At the national level, researchers (including those in university teams associated with research center programs) are offered remuneration incentives and bonuses, satisfactory working conditions, multiple professional training programs, advancement opportunities, as well as housing (often built near the workplace) and various facilities (food supplements, transportation services, etc.).

One of Cuba’s successes in medical strategy has been to strengthen its national sovereignty by substituting imports with a wide range of domestically manufactured medicines and converting exports into a driving force for the country’s growth. Indeed, a maximum number of medical products essential to meeting the needs of the Cuban population, but difficult or even impossible to purchase abroad due to their high prices or inaccessibility because of the embargo, had to be developed locally. It was a long, delicate process, but gradually the foreign-sourced medicines distributed by the island’s pharmacies were replaced by domestically manufactured products—sometimes copies of what exists on world markets, sometimes island inventions, both requiring a high level of expertise (especially in genetic engineering). Cuba can now offer medications to the health authorities of foreign countries for purchase and registration, under intellectual property protection if possible or desired, and with advanced technologies ready for use on an industrial scale.

As a consequence, Cuban pharmaceutical and biotechnological products contribute to boosting exports and providing them with high added-value content. For such goods, Cuba’s advantage lies not only in their quality but also in their prices, which are low enough to be accessible to southern poor countries. For example, the CIMAvax vaccine distributed abroad by the CIM costs barely one dollar per injection, which is much cheaper than any other treatment for lung cancer. Similarly, the custom-made hearing aid for children sold on the global market by CNEURO costs two dollars, which is very low compared to the prices of equivalent devices in Europe or the United States. The same is true for generic penicillamine antibiotics (Amoxicillin or Ampicillin), which are in high demand. The low cost of Cuban exports, therefore, encourages many countries in the Global South to purchase them. For Cuba, external markets are essential to benefit from economies of scale, overcome the narrowness of the internal market, and offset the fixed costs of R&D activities with the large volumes sold (Campbell, 2022). The island’s annual revenue from exports of medical goods and services amounts to several billion dollars (between two and five) (ONEI, various years).

Despite the progress Cuba has made in public health, problems remain. Pharmacies and even hospitals are frequently lacking certain medicines or equipment, including those manufactured on the island. The reduced availability of these goods worsened during the COVID-19 pandemic, because priority was given to the production of drugs and vaccines for anti-Covid protocols. Such a phenomenon—sometimes accompanied by illegal sales—can mainly be explained by the insufficiency of the inputs necessary for this production: In some cases, logistical obstacles hamper supplies; in others, suppliers cancel their deliveries; in still others, foreign banks refuse their services to Cuban entities even when the latter have the means to pay for their orders; and so on. It has also happened that a foreign pharmaceutical firm is authorized in its own country to conduct clinical trials on a Cuban drug, but the country’s administration refuses to market it. This was the case, for example, with Heberprot-P in the United States.

Furthermore, despite their importance, Cuban exports of medical products are facing a relative concentration of their destinations. The diversification of outside markets is, therefore, becoming a necessity (Herrera, 2025). The Cuban pharmaceutical and biotechnology industries are also confronted with the need for an injection of additional resources. As a matter of fact, their success will depend not only on opening new external outlets but also on the creation of innovative products. A dilemma, therefore, arises here, especially as patent terms expire and the race for innovation intensifies: whether to continue manufacturing medicines that require less investment but are less profitable, or to increase efforts to significantly renew product lines, which, then, involves greater risk-taking and resource commitment, but at the same time offers better prospects for returns and long-term growth.

Obstacles Imposed by the United States: Embargo, Poaching, and Biological Attacks

However, it should be recognized that the main reason for the difficulties in accessing external capital, export markets, or foreign partners, and for the recurring problems of medical product shortages encountered in Cuba, is, undoubtedly, the embargo imposed by the United States. One of the challenges the Cuban citizens must constantly face, day by day, is trying to find ways to circumvent it. This embargo causes multiple economic damages to the island (MINREX, 2022) and, by organizing shortages, immeasurable sacrifices and cruel suffering to its people. In effect, since 1962, this US set of unilateral sanctions was extended to pharmaceuticals in 1964. While occasional trade in such products was subsequently tolerated, the threat that these coercions pose to US companies and citizens, as well as foreign ones—due to the extraterritoriality of these measures—effectively extends their reach to areas formally excluded from the texts, such as medical products and equipment. There is indeed a real risk of being sentenced to heavy fines by US courts in the event of proven violations of the embargo. Numerous foreign pharmaceutical companies that have expressed a desire to sell their products in Cuba, or on the contrary to purchase Cuban goods, have been dissuaded from doing so.

The pressure exerted by the US Departments of State, Commerce and Treasury on Cuba’s suppliers has in fact concerned the acquisition of medicines not manufactured on the island: laboratory products, radiology and surgical instruments, defibrillators, dialysis machines, spare parts, etc. These restrictions go as far as preventing the supply of anesthetics (including epidurals), infant food, or equipment for pediatric intensive care units (AAWH, 1997). They complicate the full implementation of certain protocols, especially against childhood leukemia, breast cancer, cardiovascular or kidney diseases, among others. They especially affect the most vulnerable groups of people: children, pregnant women, the elderly, and patients suffering from chronic diseases. This is inhumane. A humanitarian tragedy was only avoided by the determination of the Cuban revolutionary government to maintain the socialist model that guarantees free access to healthcare for all. Nevertheless, by attacking the Revolution’s successes, the embargo compromises further progress and jeopardizes the achievements of the National Healthcare System.

In late 2017, President Trump banned US companies and citizens not only from exporting products to Cuba containing components manufactured in the United States (as already required by law before his time) but also from trading with Cuban public institutions, including research centers. This was under a so-called “grandfather clause,” which allowed the Roswell Park Comprehensive Cancer Center to continue the collaboration, its researchers had begun with those of the CIM in Havana. Under the Biden administration, most of these sanctions remained in effect, even during the COVID-19 pandemic, when Washington refused to sell Cuba inputs for the manufacture of medicines or components for vaccines, as well as medical oxygen and life-saving equipment such as ventilators. Faced with this situation, as early as 2020, the Cuban company Combiomed began producing the very first high-performance pulmonary ventilator for intensive care units (Combiovent), designed to provide ventilatory assistance to patients unable to breathe independently. ⁴

The attacks of the US authorities on the freedom of movement of scientific personnel and knowledge have led for years to restrictions on travel and professional stays in Cuba for US researchers; noncompliance with bilateral visa agreements granted to their Cuban counterparts; bans on the publication in the United States of scientific articles and works written by Cuban authors; inaccessibility or nonregistration of patents; refusal to grant software licenses; and rejection of orders placed by Cuba, among others, for specialized books, journals, or databases published in the United States. This has virtually blocked opportunities to develop intellectual exchanges and cooperation.

However, this embargo can also backfire on the US population. Here, one example will suffice. For several years, the importation of the Cuban meningococcal vaccine Va-MenGOC-BC was obstructed by the US Department of the Treasury. The intervention of researchers from around the world and the mobilization of deserving members of parliament and citizens in the United States finally forced the administration to back down, and it finally authorized its purchase. Belatedly, alas: in the meantime, nearly 500 young Americans had died from meningococcal B meningitis, the majority of them children. For their part, despite the embargo, the Cubans continue to act in their own way, sometimes by sending vaccines free of charge if the leaders of foreign countries affected by epidemics are reluctant to buy them for fear of reprisals from Washington, sometimes by bringing innovations to their foreign partners within joint ventures, such as, for example, with immunological therapies to fight cancer.

Another obstacle that the United States has imposed on the development of the Cuban health system is the encouragement of the emigration of professionals in this sector. Promoted by the US Departments of State and Homeland Security since 2006, and supported by propaganda from anti-Cuban NGOs and media in Miami, the Cuban Medical Professional Parole (CMPP) program has aimed to induce brain drain and desertion of Cuban healthcare workers on assignment abroad by granting them visas to emigrate to the United States. The latter relaxed this device in 2016, at the same time as the Wet Feet-Dry Feet policy which, in violation of past migration agreements, encouraged illegal emigration by preferentially granting Cubans permanent residency one year after their arrival on US soil. Visas and plane tickets to Miami were issued by its embassies in 65 countries. US immigration services report some 7,000 Cubans benefiting from the CMPP program, half of them coming from Venezuela (often via Colombia or Curaçao). The requirements were to be Cuban citizens, work as a doctor, nurse, physiotherapist, or laboratory technician in an official mission in a third country, and be eligible for entry to the United States. The spouse or husband and children (unmarried and under 21) of the applicant could accompany him or her if they were abroad with him or her, or, if they were in Cuba, wait until he or she had a visa to apply for one themselves. In Venezuela, for example, 5% of Cuban doctors are said to have deserted the program. Washington constantly pressures foreign leaders to end the hosting of Cuban medical missions, as during the presidencies of Bolsonaro in Brazil (2019–2023) and Áñez in Bolivia (2020). Despite this sabotage by poaching, Cuba continues to provide assistance to international health institutions and to people around the world in need.

One aspect of Cuban–US relations that is little known to the general public is the biological attacks organized from the territory of the United States for the purpose of infecting the Cuban population, livestock, and crops. Such attacks could only be exposed when Cuba had highly skilled researchers at its disposal. It was indeed the investigations conducted by the Animal Health Division of the National Center for Scientific Research that revealed the causes of the African swine fever epidemics of 1971 and 1980. Another example of the use of these terrorist means, which amounted to veritable biological warfare against Cuba, was the spread of dengue hemorrhagic fever, an epidemic that hit the island in 1981 (New York Times, 1981). It was proven by Cuban researchers who, by using bioinformatics tools, amplified and sequenced the complete genome of strains obtained at various times during the epidemic, that this type of dengue, unknown at the time, had been developed in a laboratory in the United States to spread it on the island (Cabrera, 2016). After vaccinating soldiers at its military base in Guantánamo, Washington banned its firms from supplying insecticides and spraying planes to prevent the virus transmission. The epidemic, which affected 350,000 people in Cuba and killed 180 people, including 101 young children, was only stopped thanks to the use of interferon that the Cubans had just produced. Other similar operations have come to light, such as the case of the tristeza virus found in 1992 at Havana airport in the luggage of a US traveler. One might think these “stories” were fabricated by the Cubans, but such an argument is difficult to defend when the strains that were detected were for the first time on the island (as was the case with the Shiguella 1 dysentery bacterium in 1982), in the Americas (with hemorrhagic conjunctivitis in 1981 or Acaro Steneotarsonemus syndrome in 1997), or even in the world (such as the previously mentioned type of deadly dengue fever, or DENV-2 New Guinea 1924). However, everything becomes clear when members of criminal organizations operating from US territory publicly admit to having participated in such terrorist actions (as happened after the intentional release of the modified swine fever virus in 1979) (Agresiones de Estados Unidos a Cuba, 1979).

Conclusion

The continued affirmation of the priority given to public health and medical research by the revolutionary government since 1959 explains Cuba’s good results in this area. Indeed, the island’s indicators are better than those of most countries in the South and comparable to those of the North. A brief examination of the statistical data published by international organizations immediately demonstrates this: For example, Cuba has not only caught up with but now surpassed the United States in terms of life expectancy (longer) and infant mortality (lower) (World Bank, 2024). Such successes are objectively measurable in multiple achievements: The state of health of the population, pharmaceutical and biotechnological production, a number of innovations created or patents registered, exports of medical goods and services, and internationalist missions abroad. Thus, beyond the uniqueness of its historical trajectory, Cuba proves that it is possible, through the participation of a people and the will of a state, mobilized together, and both revolutionary, to build a National Healthcare System and research centers and place them at the service of individual and collective well-being.

Moreover, Cuba has today become a destination for “medical tourism.” The quality of an internationally renowned health system is a decisive argument, combined with very affordable prices and time savings, to convince foreign patients to seek treatment in Cuba—all under standard tourist visas. The most frequently requested medical services are cancer treatments, prosthetic implants, ophthalmology procedures, detoxification cures, and plastic or cosmetic surgery. The costs of these services for foreigners are on average 75% lower than in the United States, for equivalent quality. So, tens of thousands of patients, mostly from the Americas and Europe, choose to come to Cuba for surgery or specific treatment. Among the most common nationalities are those from Canada, the United Kingdom, and Mexico—not to mention the United States, often traveling via a third country. At present, Cuba is generating valuable revenue (approximately $6–10 billion annually in total) from all its medical cooperation and exchanges with other countries (Herrera, 2025).

Cuba’s health achievements have long been internationally recognized. To illustrate this fact, here are a few examples: Cuba received the World Intellectual Property Organization’s Gold Medal for the discovery of the meningitis B vaccine (in 1989); the “absence of racial barriers to access to healthcare in Cuba” was praised by the American Public Health Association (1996); this system was described as a “model for the South” by the American Association for World Health (AAWH, 1997); The Economist speaks of the island’s “impressive range of genetic engineering products” (2003); the Haemophilus influenzae type B vaccine was seen as a “scientific feat” by the journal Science (2004); Cuba is the first and only Latin American country without child malnutrition, according to UNICEF (2010); “the best country in the South to be a mother,” according to the British NGO Save the Children, and the first country in the South for the UNDP Human Development Index (2011); its free system was applauded by the New England Journal of Medicine, and cited as a “model” by The Lancet (2013); its results were praised by the WHO, as its doctors who fought against Ebola by Science (2014); Cuba is “an example of solidarity,” according to the WHO, and UNESCO congratulated it for the creation of the ELAM (2015); the World Psychiatric Association praised the treatment of mental illness on the island (2016); the WHO Public Health Prize was awarded to the Henry Reeve Contingent (2017); during the COVID-19 pandemic, the New York Times extolled Cuba’s internationalist missions (2020); the Washington Post did the same for the discovery of anti-Covid-19 vaccines (2021), and so on. At last, leading scientists, from French mathematician Laurent Schwartz, Fields Medal winner, to US biologist Peter Agre, Nobel Prize winner in chemistry, were not stingy with their compliments for the health system and medical research implemented in Cuba thanks to its socialist Revolution. ⁵