AVANA — The retired accountant went to her neighborhood health clinic one Friday last month for a scheduled blood pressure check. Doctors noticed 74-year-old Elsa Pérez Garcia’s red eyes and skin rash and immediately suspected Zika virus.
The week before, her neighbor, Rosalina Coffigny Acosta, 52, had noticed a similar rash as well as joint pain, fatigue, and swelling in her cheeks. She walked two blocks to the same clinic — run, like all health services in Cuba, by the government.
Tests determined that Pérez Garcia had Zika and that Coffigny Acosta, along with her husband and 20-year-old son, had dengue, another mosquito-borne condition. Doctors hospitalized all of them for eight days in beds surrounded by nets to keep mosquitos from biting them and spreading their illness. Meanwhile, fumigation squads sprayed their homes and their neighbors’.
“It smelled like gasoline when we came back,” Acosta said. “I had a big cleaning job to do.”
In Cuba, the fight against mosquito-borne diseases is hyper-organized, intrusive, and remarkably effective. On disease trackers’ epidemic maps, Cuba is an island in a sea of Zika: Virtually the entire Caribbean has experienced widespread transmission of the virus, but global health officers say there has been only “sporadic” spread in Cuba.
The Obama administration’s top health official praised Cuba’s efforts to prevent transmission of Zika and other mosquito-borne viruses during a scientific meeting here last month. “What it takes is local communities doing very strong vector control,” Health and Human Services Secretary Sylvia Mathews Burwell said at a press conference at the recently opened US Embassy. “I think it is what they’ve been successful with.”
Other countries could learn from Cuba’s response to Zika, public health experts said. “The great difference between Cuba and the rest of Latin America as well as the US is that Cuba tried to anticipate the arrival of the virus to mitigate the impact,” said Carlos Espinal Tejada, a tropical disease specialist who directs the Global Health Consortium at Florida International University in Miami.
“In Miami and in places in Latin America, they waited until they had cases and then mobilized,” Espinal Tejada said. “In Cuba, it’s the opposite. When they see a virus about to arrive, they mobilize.”
Cuba began building a system to aggressively track and prevent mosquito-borne diseases after a 1981 outbreak of dengue fever killed 158 people, said Carilda Peña García, director of vector control for the Cuban health ministry. “The Cuban people don’t forget that,” she said.
Cuba’s success in limiting Zika’s spread is due largely to prevention efforts coordinated from local health clinics. In addition to doctors and nurses, these clinics deploy 15,000 workers — in a country of 11 million people — who “visit every house in Cuba” to look for mosquitoes and kill them, said Peña García.
In Havana, each mosquito-control worker is responsible for 280 to 300 households and is expected to visit 20 each day, checking for mosquitos, larvae, and standing water that could become breeding grounds, said Nilda Roca Menendez, director of health and epidemiology for Havana.
If a case of Zika, dengue, or chikungunya virus is diagnosed, or mosquitos or larvae are found, every home within 100 meters will be checked more intensely, Roca Menendez said. If a second case or infected home is identified, that radius is extended to 300 meters.
People who travel abroad are closely tracked. During an interview at Polyclinic 15 y 18 in Havana’s Vedado district, Roca Menendez pulled out an address list for 33 area residents who had recently returned from other countries. Doctors will monitor them for two weeks after their arrival, she said.
Pregnant women are also screened for Zika because of the risk their babies could have serious brain damage. Acosta said she shared a hospital room at Pedro Kouri Institute with two Zika-infected women who were seven months pregnant. When doctors explained the risks of birth defects, both elected to have abortions, she said.
“They had been carrying their babies for seven months and were very sad,” she said. “They were crying a lot.”
The intensive efforts to thwart Zika appear to be paying off. Cuba has recorded just three cases of the virus caused by a mosquito bite inside the country, although most cases are mild and go unreported. (In comparison, 211 cases of local spread have been confirmed in South Florida.) Since these three cases were reported in August, however, outbreaks causing local transmission have occurred in Havana and two other cities, said Cristián Morales Fuhrimann, the Pan American Health Organization’s representative in Cuba. Garcia is among the new cases, but they have not been reported to international authorities.
“We have had some degree of local transmission in three provinces in the country but that has remained under control,” said Peña Garcia of Cuba’s health ministry.
Cuba’s experience highlights the importance of preparing the health system to respond quickly, detecting infection as soon as possible, and involving the public in the effort, Fuhrimann said. “If you don’t have people engaged, you won’t be able to succeed,” he said.
‘Not many people want this job’
The mosquito control campaign is not universally popular among Cubans, however. Many residents say they resent inspectors coming into their homes and worry that inspectors or fumigators may steal from them. Workers complain of being underpaid, overworked, and unprotected from the toxic chemicals they spray.
Outside one clinic in Havana last month, a group of young men clad in khakis finished their lunch before resuming their inspections. Future university students, they had been assigned to mosquito-control work during their year of mandatory military service.
In the first five weeks of their deployment, said an 18-year-old who gave his name as Abel, they worked seven days a week but now have a more normal schedule.
“We’re aware of the importance of the job we’re doing, helping stop the spread of disease,” Abel said, but he and his companions don’t like being compelled to do it.
Their lack of motivation can negatively affect their work, Abel said, so bosses supervise them closely. If mosquitos turn up in a house they’ve previously checked, they could be disciplined, have their military service extended or be prosecuted for spreading disease, Abel said, though he didn’t know of anyone who had been punished.
More serious complaints came from a group of fumigation workers gathered after work in a park, spray guns at their side. One, who gave his name as Yasmani, said he’d been doing the job for four years. His pay, he said, is 490 Cuban pesos a month (about $20), plus up to 200 pesos more for overtime — barely enough to live on.
“Every day you’re carrying this heavy equipment, up and down stairs,” he said. “Not many people want this job.”
What’s worse, he said, is that the workers spray the insecticide inside homes without wearing gas masks. “It’s not healthy,” he said. A few months ago, he had headaches and flu-like symptoms every day for 15 days. A doctor at the polyclinic told him the fumes were to blame, he said.
At an annex next to Polyclinic 15 y 18 that serves as a dispatch point, Julio Batista, a mechanic, tinkered with fumigation machines, improvised devices with two fuel tanks, blackened metal nozzles, and exhaust pipes. He pumped a lever on one, and it started with a roar like a gasoline lawn mower.
Fumigators use a mix of diesel and a chemical in their spray guns, said Antonio Bell, 50, a supervisor of mosquito-control workers who wears a faded blue “campaña anti-Aegypti” (campaign against Aegypti) baseball cap. Aedes aegypti is the main mosquito species spreading Zika.
The fuel contains lead, which remains in suspension form in the aerosolized insecticide the machines spew out, he said.
“Every six months, we send the workers to Rampa Polyclinic to get a checkup” to see if they’ve been affected by the residues, Bell said. “Sick workers are not too common” because they check them so often.
Bell started five years ago as a fumigator, was promoted to vector-control worker, and then to supervisor. He’s studying to become an epidemiology worker, learning about mosquitoes, rats, and other disease-carrying vermin. He confirms the salaries reported by the vector-control workers and said he, as a supervisor, earns 720 pesos a month (about $29).
As Bell spoke, Raycler Duro, a supply manager, walked over with a gas mask, one of 20 left at the clinic by an Army unit deployed there three months ago to fumigate homes. The masks have been sitting — unused — in storage ever since, in case the Army returns for them.
Seeing Cuba’s vigilance up close
A US researcher visiting the island recently saw Cuba’s vigilance first-hand. Arachu Castro, a Latin America specialist at Tulane School of Public Health and Tropical Medicine in New Orleans, was traveling in a rural area when her young adult daughter became sick with a high fever.
“She was immediately enrolled in the dengue prevention program, picked up in an ambulance, and hospitalized in a provincial hospital under close clinical observation,” said Castro, who isn’t related to Cuba’s current or former president.
She was allowed to bring her daughter by taxi to Pedro Kouri in Havana, where tests for the dengue, Zika, and chikungunya viruses came back negative.
“My daughters had heard me say over the years how the Cuban public health system works,” Castro said. “The one who got sick kept saying, ‘At least I’m in Cuba.’”