@ Cynthia Adina Kirkwood
Solidarity Fighting Pandemic in Belize, Cuba and Puerto Rico
COVID-19 testing site on Belize’s Caye Caulker, a popular tourist spot
The Caribbean features variety in people, natural beauty and its approach to battling COVID-19. Belize, Cuba and Puerto Rico have different strategies based on their history, politics and cultural values.
The two nations and one United States territory promote handwashing and sanitizing, physical distancing and masking as three of the pillars of preventing the spread of the virus. The fourth pillar is the vaccine. However, they stress that the vaccine will not be successful without the other three and that the vaccine, though essential, is not a silver bullet.
Detected one month ago, the Omicron variant, even more transmissible than its predecessor, Delta, has increased case numbers explosively in these countries as elsewhere. With the pandemic two years on, some countries are re-examining their programs,
Effective campaigns feature solid organization, good communication, statistical information and shared goals. They tend to issue from countries that are community- not individually- oriented. Also, wealth is not a factor for success.
Puerto Rico has an underfunded healthcare system, high levels of poverty and an infrastructure still devastated by a hurricane in 2017, reported France 24 (November 10, 2021) as well as a series of earthquakes in January 2020, according to The New York Times (March 1, 2020).
Yet, Puerto Rico is one of the top three United States jurisdictions, alongside Vermont and Guam, with the highest rates of COVID-19 vaccinations, according to NBC News (December 23, 2021).
In a population of 3.2 million, 3,393 people have died of COVID-19, according to Our World in Data (January 10).
A total of 77.5 percent, or 2.48 million of the population, has been fully vaccinated and 6.05 million doses were administered as of January 5, according to Our World in Data. Less than 40 percent of the population has received a booster, reported Vox (January 9, 2022). However, not everyone is eligible as yet if six months have not elapsed since their last shot of Pfizer or Moderna, or three months with the Johnson & Johnson (Janssen) vaccine.
Experts credit a sense of solidarity and a public health response untainted by political polarization. Scientist Monica Feliu-Mojer told National Public Radio (NPR) (November 29, 2021):
“Solidarity is at the core of what it means to be Puerto Rican. Culturally, we are family- and community-oriented. Truly, we take care of each other. So, that solidarity, that caring for the other person, empathy, is manifested to people pretty much universally masking.”
Sensing the gravity of the pandemic, an immediate response to the pandemic was a never before seen coalition of community groups, non-profit organizations of scientists, and the government, said Feliu-Mojer of Ciencia Puerto Rico (Science Puerto Rico), a non-profit group of scientists, professionals, students and citizens committed to advancing science in Puerto Rico.
Organization was key to Puerto Rico’s success.
As vaccines began to move toward authorization at the end of 2020, the Puerto Rico Department of Health (PRDH) asked the U.S. Centers for Disease Control and Prevention (CDC) for technical assistance to plan a vaccination campaign. Five people from the CDC office in San Juan were given the immense task of getting vaccines into people’s arms to help stop the pandemic,” according to the CDC.
The CDC Puerto Rico team was led by a lead epidemiologist. It included an IT (Information Technology) specialist; a second epidemiologist; a recruitment specialist; a logistics specialist, and an emergency management specialist. According to the CDC:
“The Puerto Rico-based team normally studies dengue, a mosquito-borne disease common in the region. Since the beginning of the pandemic, CDC has supported local response efforts with data analysis, epidemiology, laboratory science, and other services. With this experience, the dengue team was able to quickly turn its focus to getting COVID-19 shots in arms.
“The team developed online resources to speed up the process of getting vaccine providers enrolled, helping increase the number of providers from 20 to more than 550.”
Oscar Padro, the IT specialist, said:
“PRDH was receiving many calls and emails from providers about how to register, slowing the process considerably. We developed new digital tools that improved the workflow, including an online provider registration form.”
Working with the Puerto Rican National Guard, the logistics specialist helped develop a vaccine distribution system that shipped vaccines to central hubs, where Guard troops then distributed them to providers. This system provided the most complete island-wide data on total distributed vaccines.
Meanwhile, Eunice Soto, the recruitment specialist, identified and enrolled vaccine providers to ensure island-wide coverage.
“Puerto Rico has a solid healthcare infrastructure with experienced vaccine providers,” said Soto. “Hospitals, federally qualified health centers, and primary care centers were quickly brought up to speed to become the first line of vaccinators. Recruiting non-traditional vaccine providers in rural areas, where fewer vaccine providers were available, was essential to ensure availability across the island.”
In addition, the team trained more than 1,000 healthcare providers and vaccination staff on how COVID-19 vaccines work and their possible side effects. After the CDC team left, PRDH’s Immunization Program’s experienced trainers have continued to train nearly 20,000 providers.
Communication was essential in the effort.
Epidemiologist Liliana Sanchez-Gonzalez was tasked with ensuring that providers “had all the training and education resources they needed. First, we developed a COVID-19 vaccination website with online training and education materials. The Spanish website quickly became one of the top online resources for information on COVID-19 vaccines.”
How is misinformation (unintentional false information) and disinformation (intentional false information) combatted?
“One of the projects of my organization working with other nonprofits was a rumor-tracking project working with community leaders who were our eyes and ears in the community,” said Feliu-Mojer of Ciencia Puerto Rico. “Puerto Rico WhatsApp is very popular and used as a community tool. Often, community leaders got misinformation and disinformation on WhatsApp, and they would report it back to us.
“There were a lot of rumors, and they were in a few categories: the safety and effectiveness of the vaccines; how fast the vaccines came to market, and government mistrust, which is general in Puerto Rico.
“So, we created materials that responded to these rumors and shared them on social media and, most importantly, with community leaders.”
In a fast-moving environment, when new programs are being rolled out and the virus itself is changing, clear and timely communication is essential. The CDC team kept weekly office hours. Gabriela Paz-Bailey, lead epidemiologist, kept communication flowing among the CDC, PRDH leadership and the Immunization Program.
Over time, vaccination rollouts tend to reach plateaus. Projects to encourage people to get vaccinated are helpful. In the summer of 2021, Voces Coalicion de Inmunizacion y Promocion de la Salud en Puerto Rico, Direct Relief and Facebook Data for Good conducted an online study that showed that the use of local celebrities may be effective in vaccine promotion among the young, according to Direct Relief (October 1, 2021).
The effectiveness of four separate ads, each featuring a different celebrity, was tested among two target audiences: those 18-34 and those 35 and older. The three-week study began in mid-August. It reached more than 486,000 people in Puerto Rico, and it garnered nearly 38,000 visits to Voces’ vaccination clinic calendar.
The celebrities in these ads were musical artist VF7, members of the Vaqueros de Bayamon Puerto Rican professional basketball team Benito Santiago and Victor Carattini, former professional baseball player Carlos Delgado, and Puerto Rican actress/comedian Angela Mayer. With the onslaught of Omicron and a 4,600 percent increase in cases, Puerto Rico expanded its already existing restrictions, reported The New York Times (January 2, 2020).
Governor Pedro R. Pierluisi ordered lower capacity limits in restaurants. To attend large public events, people have to be vaccinated and present a negative COVID-19 test. Passengers arriving on domestic flights must show a negative test taken within 48 hours before arrival. Similar rules already were in place for international flights.
Mass public events, including the celebration of the 500th anniversary of San Juan, were canceled. “Dick Clark’s New Year’s Rockin’ Eve”, which ABC planned to broadcast live from Puerto Rico in front of big crowds, was downgraded to a virtual event. The Miss World pageant final was canceled.
The Scientific Coalition, a group of scientists and health professionals that had been advising the governor, recommended stricter measures such as limits on liquor sales and shorter hours for bars, reported The Times. The next day, the governor followed the recommendations. He also mandated boosters for restaurant employees and public safety workers.
At home and abroad, post-revolutionary Cuban identity always has been bound up with health, according to The Lancet Infectious Diseases (April 2021). It is the only country in the Caribbean and Latin America to have produced a COVID-19 vaccine, reported CNBC (January 13, 2022).
In the 1980s, Cuba developed the world’s first meningococcal B vaccine. It produces eight of the 10 routinely used vaccines in the country, and it sends hundreds of millions of doses abroad. Malaria, tetanus, polio and measles have been eradicated in the country.
When the pandemic began, Cuba’s scientists and doctors at 30 research institutions and manufacturers, under the aegis of the state-run conglomerate BioCubaFarma, began developing a vaccine and came up with five, two of which are being administered while the other three are still in development.
“The United States’ 60-year-old embargo against the country, which prevents U.S.-made products from being exported there, would make it difficult for Cuba to acquire vaccines and therapies, researchers and officials knew,” according to Nature (November 22, 2021).
“It was best, for protecting our population, to be independent,” said Vicente Verez Bencomo, director-general of the Finlay Institute of Vaccines in Havana.
A total of 85.8 percent of the population has been fully vaccinated, according to Our World in Data as of January 5. The number of deaths caused by COVID-19 was 8,880 in a population of 11.3 million, reported Our World in Data (January 10).
“Cuba’s successful response to COVID-19 was largely a result of years of investment in primary care and assiduous attention to population health,” reported The Lancet Infectious Diseases.
“The country has comprehensive universal health care and one of the highest doctor to patient ratios in the world.”
Clare Wenham, assistant professor of global health policy at the London School of Economics (LSE), told The Lancet Infectious Diseases: “Everyone has a yearly routine check-up and, if you do not go, the doctor will come and find you.
Disease outbreaks can be detected more or less immediately. Under a model known as CARE, patients are stratified into four categories: apparently healthy, at risk of disease (such as being overweight, diabetic or hypertensive), unwell, and in rehabilitation or recovery, according to The Lancet Infectious Diseases.
“When Cuba registered its first case of COVID-19 on March 11, 2020, it already knew the whereabouts of its most vulnerable citizens.”
Wenham pointed out:
“The public health network is very strong in Cuba, but it comes at the cost of civil liberties. Cuba is a very specific context. Not many countries are going to accept that kind of close medical surveillance, and most governments do not have such tight control over their citizens.”
Spearheaded by doctors, Cuba immediately aggressively tested, traced and isolated patients, according to the British Medical Journal (BMJ) (August 25, 2021). By April 2020, more than 1,000 Cuban health-care workers were helping foreign countries, including Belize, respond to COVID-19, reported The Lancet Infectious Diseases.
At home, doctors, nurses and medical students went door to door, advising residents on COVID-19 symptoms and searching for the possibly infected patients. Those with confirmed infections were sent to state-run isolation centers to cut transmission chains.
Because of the increased scale of the epidemic, people with confirmed infections now are monitored at home. And the country’s economic collapse is making it increasingly hard for people to stay indoors,” said Amilcar Perez-Riverol, a former researcher at Cuba’s Centre for Genetic Engineering and Biotechnologies (CIBG), which developed the Abdala vaccine.
CIGB reported that Abdala, a three-dose vaccine, was 92.4 percent effective in Phase III trials that included more than 48,000 participants, reported Nature. The other vaccine is Soberana 02. (Soberana means “sovereign” in Spanish.) CIGB researcher Merardo Pujol Ferrer said that 24 million doses have been administered to 8 million people in Cuba, giving the researchers a large data set with which to track efficacy and safety.
The Abdala, named for a poem by national hero Jose Marti, is being administered in St. Vincent and the Grenadines, reported Loop (December 18, 2021).
Cuba became the first country in the world to vaccinate children from the age of two against COVID-19, according to France 24 (September 24).
Ferrer said that the team planned to publish its data on Soberana 02 in late November, reported Nature. Peer-reviewed studies of Phase III trials also have not been published of Abdala. Cuba has asked the World Health Organization to approve the two vaccines. The Pan American Health Organization (PAHO) is pressing Cuba’s government to publish in scientific journals, which would allow it to distribute them through the COVAX (COVID-19 Vaccines Global Access) scheme to low- and middle-income countries.
All of Cuba’s COVID-19 vaccine candidates are protein vaccines, which are conjugate vaccines that combine a weak antigen with a strong antigen to boost immune response, according to The bmj (British Medical Journal) (August 5, 2021). In the case of Soberana 02, the protein from the virus’ receptor binding domain, or spike, is combined with a tetanus toxoid.
Conjugate vaccines do not require extreme refrigeration, are cheap to produce and are easy for the country to manufacture at scale. They are fermented in mammalian cells, a process Cuba already uses for monoclonal antibodies.
In July 2021, discontent with worsening shortages of food and medicine, power outages and a lack of liberalization in governance boiled over into the largest protests against the Communist government since it took power in 1959. Government crackdown was swift: more than 1,300 were detained and 620 bound over for trial, according to The New York Times (January 14, 2022). This week, prosecutors put on trial more than 60 citizens charged with crimes, including sedition, for taking part in the demonstrations. Mass trials began in December 2021.
In August 2021, William Leogrande, Cuba specialist and professor of government at American University in Washington, D.C., told The bmj:
“The surge in COVID infections in Cuba has now become a source of popular discontent, so the government’s ability to quickly vaccinate the public has political as well as public health implications.
“If the Cuban vaccines work as advertised and the government can distribute them quickly enough to get the pandemic under control again, it will relieve one source of the public’s frustration.”
Belize is neither a Communist government nor a U.S. territory. It is a stable parliamentarian democracy that delayed independence from the United Kingdom until 1981, largely because of Guatemala’s long-standing claim to it.
About 16 percent of Belizeans live abroad, as did my parents, the majority in the United States, while 15 percent of Belize’s population are immigrants, mainly Guatemalans, Salvadorans and Hondurans, according to Caribbean Migration Consultations.
At the beginning of the crisis, Belize was one of the countries in the Caribbean and Latin America with the lowest rates of infection. The country had been locked down, and people adhered to wearing masks properly, physical distancing, and handwashing and sanitizing. One doctor recalled that shop customers would hold back from walking down aisles where there were other people.
However, in September 2021, it was clear that Belize was in trouble with a sharp increase of infections, hospitalizations and deaths. The highly transmissible Delta variant had arrived two months earlier, and vaccine take-up was frighteningly low.
On September 16, 2021, only 19 percent of the population of 400,000 had been vaccinated fully, according to the Belize Ministry of Health and Wellness. As of October 1, the percentage had increased to 31.5, reported the Pan American Health Organization. As of November 15, 47.5 percent had been vaccinated completely, more than doubling the rate two months earlier, according to Our World in Data.
It was 50.4 percent on January 5, reported Our World in Data.
The vaccination rate seems to have reached a plateau. The Ministry of Health’s goal last year was 70 percent.
There have been 608 deaths, according to Our World in Data (January 16, 2022).
To encourage vaccination, the government initiated a vaccination raffle for eight weeks with the first drawing on December 1. Each week, prizes total $7,500 for eight winners – 1 at $3,000; 2 at $1,000, and 5 at $500.
Those aged 12 to 17, who receive their first or second vaccination between December 16, 2021, and March 15, 2022, are eligible to enter a raffle sponsored by the Ministry of Health and Smart, a subsidiary of Speednet Communications, which is the leading mobile service provider in Belize. Prizes include backpacks and school supplies.
The Belize Ministry of Health and Wellness continued to update its Facebook page with a daily COVID-19 report of vaccines and illness, a vaccination agenda and two want ads in early January for two bio-statisticians and one medical technologist. The Facebook page posts public comments, which include anti-vaccination and conspiracy ideas.
A website of the Ministry of Health is “coming soon”. However, the Health Pass App link is there as well as two documents available for downloading.
Belize is at a crossroads that presents opportunities.
In a recent shakeup at the Ministry of Health, the health minister of the past 14 months, Michel Chebat, was re-assigned to the low-key Ministry of Public Utilities and Logistics and replaced by former Minister of Youth, Sports and E-governance, Kevin Bernard, according to 7 News Belize (January 11, 2022):
“Bernard, who is a first-time Minister has a huge responsibility to take up. He enters a ministry, essentially, with no senior leadership in place: there’s no CEO (Chief Executive Officer), and the DHS (Director of Health Services) has been declared redundant, which would mean his deputy is also redundant. That’s at the top level – and, below that, public officers are demoralized and, according to the reports we get from insiders, virtually cowering at a culture of bullying and intimidation that had come to plague the Ministry under Chebat’s tenure. We have this general sentiment corroborated by multiple sources.
“And, so now, it all falls to Kevin Bernard – and, he’s nothing if not optimistic.”
“I believe that my utmost goal is to surround myself with the right people, the technical people, and to heed the advice. One thing I can say in leadership is that you don’t only lead from top to bottom but that you lead also from bottom up. You need to be able to listen to everybody around you, get the right advice. I am no doctor, but you have to be able to listen to the legal experts that will guide the best manner in which we lead this ministry.
We are in the middle of Omicron. We don’t know what other variant will come to this country. We are poised as a government to ensure that we can do our utmost best to reduce the effects of COVID in this country and the health of our nation but, at the same time, to turn things around as it relates to the services provided by all of our facilities publicly here in Belize.”
Because of donations and purchases from Mexico, the United States, Barbados, India, other countries and COVAX (COVID-19 Vaccines Global Access), Belize has enough vaccines.
“We are unique,” Dr. Atanacio Cobb, an ear, nose and throat specialist at Belize Medical Associates, told the Channel 5 program, Get the Facts (September 16, 2021). “Other countries, like Guatemala, don’t have enough. We are so fortunate to be able to vaccinate everyone.”
Those 12 and older are eligible for vaccination. Dr. Melissa Diaz-Musa, Deputy Manager for the Central Health Region, which includes Belize City, said on News Five Live (January 11, 2022):
“When we look at the targeted population from 12 and above, we know that that number goes up to about 65 percent.
“When we look in Belize City or Belize District, we can improve definitely in the 12 to 17 vaccines. We have approximately 15,000 children in that age range. We’ve only done about 6,000 fully vaccinated. So that age range, we can definitely improve.
“When we look at the people in the workplaces, the majority of persons are fully vaccinated, especially with the tourism sector, the different ministries. We see a lot of success in those areas when it comes to being fully vaccinated.
“The elderly. We have a large amount of the elderly fully vaccinated countrywide. I think we have 25,000 persons over 60, a high percentage of them are fully vaccinated.
“We’re calling out for the elderly to come in to get the booster, especially because they were in Phase I when we started to roll out vaccines, so it’s come time for them to get the booster.”
The waiting time for booster shots was reduced from five months to three, except for Janssen (Johnson & Johnson), which remains at two months, said Dr. Natalia Largaespada Beer, Technical Advisor, Maternal Child Health, on the Ministry of Health’s COVID-19 update Up 2 the Minute (November 30). If you become ill with COVID-19, wait one month after laboratory analysis before getting a booster unless you still have symptoms. If so, wait until your symptoms are gone,
Pfizer is the recommended vaccine for a booster. However, Dr. Beer said that patients’ wishes would be respected if they chose a different one.
The four vaccines administered in Belize are AstraZeneca (8 weeks between first and second jab); Pfizer (21 days between jabs); Sinopharm (25 days between jabs), and Janssen (Johnson & Johnson) (single dose).
Dr. Diaz-Musa also spoke to pediatric vaccines for children aged 5 to 11, which are one-third of the adult dose:
“At the Ministry of Health and Wellness, we are working on trying to procure these vaccines. However, these are not readily available. They’re only made by Pfizer company, and we have joined with CARICOM (Caribbean Community) in order for us to try to procure some of these vaccines. Many countries in the Caribbean have also joined in and submitted the amount that they wanted, so we’re doing it as a region.”
After two years of education online, 198 of 570 approved schools opened for face-to-face instruction in a hybrid instruction program on January 10, 2022, reported Breaking Belize News (January 15, 2022). The remaining approved schools are to open by the end of January 2022.
Schools are expected to have social distancing; washbasins to promote handwashing, and masking, according to Breaking Belize News. A sizeable section of the student population is vaccinated, and doses are available for those who are not.
“Many countries closed schools on and off over the past two years, but only six nations – the Bahamas, Belize, Brunei, the Dominican Republic and the Philippines are the others – have continued to impose nationwide closures, according to UNESCO, the United Nations Educational, Scientific and Cultural Organization,” reported The New York Times (January 10, 2022) in a story about Uganda’s reopening of schools after a two-year hiatus.
In Uganda, those critical of the long closure contend that there is a “lost generation” of students and that the government imposed strict lockdowns to retain political power. Those who support it say that it spared many children spreading the virus to their parents and becoming orphans as many have with deaths related to the AIDS virus. The Times said:
“Despite efforts at remote education, more than half of Uganda’s students effectively stopped learning after the government ordered classrooms closed in March 2020, a government agency has found.
“And the outlook is not optimistic: Up to a third of students, many of whom took jobs during the pandemic to support their struggling families, may not return to the classroom. Thousands of schools, themselves under financial stress, are not expected to reopen their doors. And countless teachers will not come back either, having turned to other work after losing their income during the shutdown.
“The damage is extremely big,” said Mary Goretti Nakabugo, the executive director of Uwezo Uganda, a Uganda-based non-profit that conducts educational research. Unless there are extensive efforts to help students catch up, we may have lost a generation.”
Joyce Moriku, the state minister for primary education, said in The Times:
”I don’t accept that there is a lost generation. What I agree to is there’s a percentage of our children who have gotten pregnant, the young boys have gotten into the moneymaking economy and others have gone into (other) things. That does not mean that we have lost the generation completely.”
Traditionally, education has been highly valued in Belize as in the rest of the Caribbean. In the 1990s, almost all Caribbean countries treated education as a priority, according to UNESCO (United Nations Educational, Scientific and Cultural Organization) in Education for All in the Caribbean (2000). Literacy levels in the Caribbean are relatively high when compared to other regions of the world.
Belizean parents and guardians seem to be concerned, understandably, with the risk of their children and teachers becoming infected with the virus while at school. Dr. James R. Baker, Jr., a respected immunologist at the University of Michigan, who was a college colleague, said this on his blog, Pandemic Pondering (January 6):
“Again tonight both on NBC and ABC news reported ‘record numbers’ of childhood COVID hospitalizations. Urgent messages about this problem were presented from physicians at leading children hospitals across the country. I was concerned as I was two days ago when I first saw similar reports.
“However, when I looked at today’s actual numbers, the date did not match the hype. Nationally, hospitalizations of children diagnosed with COVID are at slightly increased numbers, but many of them are not being treated for COVID!
“In Michigan, we have gone from 97 children hospitalized at the beginning of the week to 107 reported in hospitals today. Again, this is pediatric patients diagnosed with COVID, not actually being treated for COVID.
“The idea of sick children always gets your attention. Unfortunately, statements like ‘record highs’ and ‘double the numbers of last month’ are meaningless unless you are also given the exact numbers.”
Accurate information helps decision-making.
Belize has begun to see long lines at testing sites, some people holding umbrellas to protect themselves from the sun.
“It is still only suspected that it is in Belize, but from the significantly higher number of new infections being reported over the last two weeks, and the longer lines of people at testing sites, Omicron is probably already spreading across Belize,” reported News Five Live (January 11, 2022).
Studies to determine the variants at large in Belize are expected to have results during the week of January 17.
At one of the Belize City testing sites, Dr. Diaz-Musa explained to News Five Live (January 11, 2022):
“These long lines you see here are for testing. The majority of persons have been either symptomatic or in close contact with a positive case. So they’re waiting here to get tested and go into isolation, if testing positive.
“We have seen an increase in our positivity rate in the Belize District as well over the past three or four days. And we look at the individual clinics as well. We see like, for instance, Cleopatra, which is the flu clinic, they’re showing sometimes if they’ve tested 100 persons, only a very few negative, so the rate has increased to about 60 to 70 percent at these facilities.”
The Central Health Region reports vaccination schedules and other information on its Facebook page. The Southern Health Region also has a Facebook page as does Western Regional Hospital.
Online appointments for vaccinations can be made through the following link:
On January 14, 2022, Breaking Belize News reported that Dr. Julio Sabido has been slated as the Chief Executive Officer of the Ministry of Health and Wellness:
“First, Dr. Sabido must get over his current bout of COVID-19, which has put him on sick leave. But Minister Kevin Bernard confirmed that he has the job after various discussions and consultation.
“Dr. Sabido is the third candidate for the post in recent weeks after incumbent Dr. Deysi Mendez exited for the National Health Insurance Program and Dr. Lesbia Guerra balked at taking over after meeting with Ministry staff.”
Dr. Sabio holds two master’s degrees: one in public health nutrition from the University of Technology, Jamaica, in Kingston and one in public health from The London School of Hygiene and Tropical Medicine. His medical degree is from La Universidad Mariano Galvez de Guatemala in Guatemala City.