# Responding to COVID-19 through participation. The Cuban experience of community engagement

Anna Pomaro, Fanny Chabrol, Yadira Díaz Leal, Nils Graber, Vanesa Fernández Bereau, Dennis Pérez Chacón

► To cite this version:

Anna Pomaro, Fanny Chabrol, Yadira Díaz Leal, Nils Graber, Vanesa Fernández Bereau, et al. Re-sponding to COVID-19 through participation. The Cuban experience of community engagement. SSM - Qualitative Research in Health, 2026, 9, pp.100724. 10.1016/j.ssmqr.2026.100724. hal-05508541

HAL Id: hal-05508541

https://hal.science/hal-05508541v1

Submitted on 13 Feb 2026

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>
# Responding to COVID-19 through participation. The Cuban experience of community engagement

Anna Pomaro<sup>a, *, †</sup>, Fanny Chabrol<sup>a</sup>, Yadira Díaz Leal<sup>b</sup>, Nils Graber<sup>c</sup>, Vanesa Fernández Bereau<sup>d</sup>, Dennis Pérez Chacón<sup>b</sup>

## 1. Introduction

From a medical anthropology perspective, epidemic control strategies are not merely collections of biotechnological tools informed by objective scientific findings. Instead, they reflect specific epistemic frameworks and are deeply embedded in historical, social, and political contexts (Lynteris & Poleykett, 2018). Furthermore, epidemics bring certain populations into focus, both in terms of concerns about exposure and efforts focused on intervention and containment. These “pandemic publics”, shaped by public health interventions, can be managed as passive groups requiring education and intervention, or considered as active participants engaged in grassroots responses (Prince, 2019).

Community participation has been mobilized as a key resource in recent epidemic crisis management, such as Ebola, HIV and SARS (Loewenson et al., 2021; Mbaye et al., 2017; Wilkinson et al., 2017). However, despite being emphasized in global health guidelines (Marston et al., 2020), it was largely sidelined or excluded from COVID-19 management strategies in most countries (Cubillo-Llanes et al., 2022). Particularly in Western countries, institutional responses to the COVID-19 emergency were predominantly biosecurity-focused, hospital-centered and oriented toward individual behaviors, framing people primarily as potential virus vectors to be controlled and contained, with risk communication exclusively focused on individual conduct (Loewenson et al., 2021).

In contrast, Cuba represents a counter-example to the dominant trend of excluding the population from actively contributing to the response. Historically, Cuba has relied on its capacity and political will to mobilize large-scale human resources, in the form of a considerable number of health personnel alongside mass organizations (Burke, 2022), as well as on its primary healthcare system, which includes continuous health supervision, integration with other health and social services, and community participation (Brotherton, 2012; Rojas Ochoa, 2005).

Building on previous epidemic response practices—an area of expertise recognized in Cuban medical history even before the revolutionary period (Sánchez, 2020), and further developed through large-scale campaigns during the socialist era, ranging from the 1962 polio massive vaccination campaign (Beldarraín Chaple, 2013), to the various dengue and dengue hemorrhagic fever epidemics of 1977, 1981, 1997 (Kourí et al., 1998) and 2001-2002 (Peláez et al., 2004)— the Cuban state during the COVID-19 pandemic adopted a response strategy that increased broad public participation in order to support the range of epidemic control activities (Beldarraín Chaple et al., 2020), while implementing globally recognized containment measures such as social distancing and home isolation. This approach incorporated a wide range of community actors and socioprofessional groups, including students, public-sector workers, and local political leaders, who took on roles as volunteers and health promoters to address crisis management.

As a result, and despite limited economic resources, Cuba's healthcare system proved to be remarkably capable with regard to controlling the virus's spread, limiting mortality, and achieving a very high vaccination rate with vaccines developed by its national pharmaceutical industry.

Established narratives concerning the Cuban healthcare system and public health are characterized by a form of bioexceptionalism (Briggs, 2011), i.e., the notion that Cuba systematically departs from broader global health patterns and defies the material constraints that seemingly determine biomedical infrastructures and health outcomes. Questioning the value and exceptionalism of the Cuban healthcare system (Burke, 2013), and particularly its success in responding to the COVID-19 crisis, this study explore how this response was shaped, by focusing on how community participation was integrated into Cuba's COVID-19 response strategy, under what conditions and with what effects. In fact, while the key public health measures and protocols of Cuba's pandemic response strategy—such as mass surveillance, contact tracing, the use of isolation

<footnote><sup>a</sup> Université Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm, Ceped, F-75006, Paris, France</footnote>

<footnote><sup>b</sup> IPK - Institute of Tropical Medicine Pedro Kourí, Cuba</footnote>

<footnote><sup>c</sup> Humboldt University of Berlin, Germany</footnote>

<footnote><sup>d</sup> University of Cienfuegos, Cuba</footnote>

<footnote>* Corresponding author. Université Paris Cité and Université Sorbonne Paris Nord, IRD, Inserm - Université Paris Cité, 45 rue des Saints-Pères, 75006, Paris, France. E-mail address: anna.pomaro@ird.fr (A. Pomaro).</footnote>
centers and vaccine production and distribution—have been well documented, (Beldarraín Chaple et al., 2022; Mas Bermejo et al., 2020; Pérez Chacón & Hernández Barrios, 2021; Pérez Riverol, 2020), the role of community actors and non-healthcare volunteers has not yet been clearly examined.

Our study highlights the crucial role of non-medical personnel in supporting both local communities and the healthcare system during the pandemic. Specifically, it examines who was mobilized and in which areas of the response strategy, the dynamics of this mobilization, and the subjective experiences of those involved. Ultimately, the study illuminates the social impacts and the new questions raised by the COVID-19 pandemic within the framework of participatory epidemic response, shedding light on both the transformative potential and the inherent constraints of community participation during crises.

## 2. Research context

### 2.1. The cuban healthcare system

Cuba's healthcare system is defined as free and universal, organized into six hierarchical levels aligned with the country's political and administrative divisions. At the national and provincial levels, tertiary institutions and hospitals provide highly specialized care. Municipal-level facilities offer secondary healthcare services.

Below the municipal level is the primary healthcare (PHC) system, which has been a cornerstone of Cuban healthcare approach since the early days of the socialist period (Rojas Ochoa, 2005). PHC is structured into multiple health areas, each centered around a polyclinic. These polyclinics serve as local healthcare centers, providing laboratory services, emergency care, and specialized consultations.

Each health area has 10 to 15 *consultorios*, small clinics staffed by a family doctor and nurse. Their role includes clinical care, socio-epidemiological surveillance, health promotion, and disease prevention in collaboration with the community (Brotherton, 2012). Community actors, such as members of local sections of mass organizations like the Federation of Cuban Women (FMC), and the Cuban Workers' Federation (CTC), and elected Committees for the Defense of the Revolution (CDR) play an active role in health initiatives, in coordination and support of the PHC staff. These civil organizations group ordinary citizens on a territorial and functional interest basis (Brotherton, 2012). Historically, their extensive network has worked in tandem with the primary health care system in disseminating health education and promote public health initiatives. These organizations have played a key role in programs focused on hygiene and disease prevention, mass immunization, blood donations, and disease-control campaigns (Brotherton, 2012).

### 2.2. The COVID-19 response strategy in Cuba

Drawing on all its previous experiences from the moment the first COVID-19 case was detected, Cuba activated a comprehensive Plan for Coronavirus Prevention and Control, developed in January 2020, two months before the detection of the first confirmed case on the island. In addition, a multidisciplinary central group was formed, composed of clinicians, intensivists, pediatricians, virologists, infectious disease specialists, epidemiologists, statisticians, military doctors, immunologists, social scientists, and professionals from the pharmaceutical and biotechnology industries. This group of experts was tasked with designing and conducting research, anticipating public health strategies at a national level, and preparing the healthcare system for a potential surge in cases (Beldarraín Chaple et al., 2020).

One of the most emblematic measures of the Cuban response strategy was the implementation of active case-finding (Pérez Riverol, 2020). Family doctors, nurses, and specialists from each health area, with additional support from over 28,000 students and teachers from medical and health sciences schools, led an active screening program consisting in daily house-to-house visits, searches for suspected cases, monitoring

symptoms and testing all contacts of confirmed cases (Galbán-García & Más-Bermejo, 2021). This represented a key tool to control the spread of the virus and remarkably reduced the impact of asymptomatic and pre-symptomatic patients in driving virus transmission.

Cuba also established isolation centers, by transforming infrastructures such as schools, universities, and hotels into centers designated for low-risk suspected cases, contacts of confirmed cases, and travelers. As established in the initial response protocol, all positive cases were admitted to hospitals, while testing and transferring all their known contacts to isolation centers.

Any assessment of the effectiveness of Cuba's response to the epidemic carries the risk of either underestimating or overestimating its true impact, as conclusions depend on reporting practices, the stage of the epidemic, and the indicators used, among other factors.

An evaluation conducted approximately three months after the first confirmed COVID-19 case (Beldarraín Chaple et al., 2020), using two analytical approaches—the comparison of observed deaths and confirmed cases with mathematical model projections and the estimation of the effective reproduction number (Rt) of SARS-CoV-2—suggested that the public health measures implemented, some of them distinctive to the Cuban context (Mas Bermejo et al., 2020), contributed to flattening the incidence curve and limiting viral transmission during the initial phase of the epidemic (Galbán-García & Más-Bermejo, 2021).

However, since early 2021, two months after the reopening of air traffic, crucial for the national economy, the rates of incidence and mortality increased. Between June and August, the country experienced its worst phase of the pandemic, the most critical period of which occurred in July 2021 (Beldarraín Chaple et al., 2022). Hospitals became overwhelmed by patients suffering from severe forms of the disease. Isolation centers were now being used for confirmed cases, because hospitals had become saturated, and were eventually substituted by isolation at home measures.

Cuba reported a total of 1,115,043 cases and 8530 deaths, resulting in a case-fatality rate of 0.8% and a mortality rate of 75.31 deaths per 100,000 people. In addition, the country achieved a 95% vaccination rate for at least one dose of nationally designed and produced vaccines and an 89% completion rate.<fnref n="1" /> (Beldarraín Chaple et al., 2022).

In fact, since the beginning of the pandemic, Cuba placed significant emphasis on developing biomedical research for vaccine production, becoming the only country in Latin America to produce its own vaccines by means of its national biotechnology industry. The vaccination campaign began in May 2021 and had been extended across the entire national territory by October of that year. In 2022, in spite of the spread of the Omicron variant of the virus, the Cuban situation was kept under control thanks to the successful vaccination campaign, suggesting a high level of trust among the population regarding homegrown vaccines (Gorry, 2022).

## 3. Conceptual approach

### 3.1. On participation

Calls for population or community participation in health did not originate as a result of the COVID-19 pandemic. They have been a recurring theme in health policies and programs—particularly in primary health care and community health initiatives (Rifkin, 1996). This participatory vision was rooted in pioneering experiences from diverse national contexts since the 1960s, shaped by decolonization processes in Latin America, Asia, and Africa (Chabrol & Gaudillère, 2023).

The concept gained institutional legitimacy following the Declaration of Alma-Ata (1978), when WHO formally endorsed community

<footnote n="1">¹ COVID-19 vaccines | WHO COVID-19 dashboard (accessed February 13, 2025).</footnote>
participation in health as “the process by which members of a geographic or social community, aware of their belonging to the same group, collectively reflect on their health issues, express their priority needs, and actively participate in the implementation, execution, and evaluation of activities best suited to address these priorities.” (World Health Organization [WHO] & UNICEF, 1978).

Community participation encompasses a broad spectrum of practices. Critical studies in medical anthropology and public health have highlighted how, although initially starting out as a profoundly local and contextual approach, community healthcare experienced a shift toward a standardized, technocratic, and depoliticized interpretation of participation (McDowell et al., 2022; Morgan, 1993). Yet in practice, this ideal is fraught with contradictions and varies widely in how it is conceptualized and implemented (McDowell et al., 2022; Rifkin, 1996).

Guided by a socioanthropological approach and the political economy of health, we approach community participation as a polysemic and context-dependent concept. Conceptions and practices of community participation in healthcare processes depend on local and national political contexts, the history of national and international public health policies (Morgan, 1993) and the nature of the public health issue at stake (Bronfman & Gleizer, 1994). Like any social practice, it is shaped by local histories and sociopolitical dynamics (Reynolds & Sariola, 2018), and often carries internal tensions and contradictions. Drawing on works that analyze participation as a relational and evolving configuration of practices, spaces, and power relations, rather than as a vertical or purely normative concept (Teorell, 2006) our aim is to uncover the underlying logics that shape both the conceptual foundations and the material conditions of participatory practices or calls for participation.

Health crises such as Ebola or HIV have seen the emergence and organization of local community initiatives that engaged in forms of participation extending well beyond institutional definitions of community and public health (Reynolds & Sariola, 2018; Wilkinson et al., 2017). This phenomenon became even more pronounced during COVID-19, as research documents the emergence of various informal and grassroots initiatives in different contexts around the world, where civil society was able to respond to unfolding emergencies by helping to ensure food distribution, hygiene support, public health communication, and door-to-door visits (Carstensen et al., 2021; Duque Franco et al., 2020; Loewenson et al., 2021). These efforts frequently operated alongside, and sometimes in place of, formal responses (Manderson & Burke, 2025), addressing dimensions of the crisis that exceeded medical needs, or even countering the states' irresponsibility or unreliability in key areas (Anigstein et al., 2021; Duque Franco et al., 2020).

The multidimensional character of the pandemic, combined with the scale and intensity of these initiatives, has led scholars to speak of *pandemic solidarity* (Fernández Salvador et al., 2024)—practices of care that extend to economic, social, and emotional needs, while simultaneously reshaping social and political dynamics as well as state–citizen relationships (Loewenson et al., 2021). Independent, informal forms of mutual aid have therefore been recognized as crucial components of the global response to the pandemic.

In Cuba, this widespread mobilization and community engagement has historically been formalized and reinforced by the state, forming a core principle of state functioning since the beginning of the revolutionary process, in the late 1950s. Participation and collective action have thus been institutionalized not only as a mechanism for responding to crises (including but not limited to health emergencies), but also as an enduring feature of everyday social and political life. Our goal in this study is to examine how these forms of participation and community engagement have been activated, and challenged by, the COVID-19 crisis.

## 3.2. Community participation in Cuba

In Cuba, popular mobilization is historically very strong and linked to state leadership and planification. The construction of social

imaginaries around participation and solidarity express in the prioritization of state intervention over individual action, resulting in a leading role of the state and a top-down approach to participation (Rodríguez González et al., 2024).

Popular mobilization represents a key feature of the healthcare system elaborated during the revolutionary era, with the principle of universal healthcare considered a national priority. The Cuban constitution establishes that healthcare delivery is the responsibility of the state and that the population participates in developing and maintaining the healthcare system (Iatridis, 1990).

The mass organizations, created at the beginning of 1960s, were the main drivers of this process. Their main objective is to organize local ordinary life with political activities, collective works, and rally support around revolutionary objectives and projects (Brotherton, 2012).

During the early decades of the Cuban Revolution, participation was largely structured as mass mobilization, a period when government health campaigns were mostly centered on controlling epidemics, acute infections, and parasitic diseases. The state called upon citizens, through mass organizations, to carry out specific tasks and achieve predefined objectives. Given the centralized and technocratic nature of the Cuban healthcare system, this top-down approach to participation remained the dominant model (Soriano Fernández et al., 1999; Uriarte, 2002).

Community engagement took a new turn in the 1980s with the creation of the Family Doctors and Nurses (MEF) program, launched in 1984. This program operates more on a local scale, by strengthening the doctor-community-patient relationship – which today stands as the central feature of primary healthcare in Cuba –, prioritizing community involvement in assessing needs and adapting health responses (Graber, 2018).

Community participation is also called upon in response to epidemic emergencies. An emblematic example is the first outbreak of dengue hemorrhagic fever in 1981, eradicated in only three months, where community actors played a key role in the eradication strategy (Guzmán Tirado, 2012; Peláez et al., 2004), consisting of house-to-house surveillance, and large-scale health education initiatives (Feinsilver, 1993). Since the 1990s, in response to the structural and economic challenges linked to the Special Period, there have been efforts to experiment with bottom-up participatory approaches aimed at transforming the traditional model of community engagement (Chaguaceda et al., 2012; Ramirez, 2005). Some national health programs have aimed at integrating this turn, particularly in dengue vector-control programs that emphasize community empowerment and participation (Sanchez et al., 2009). However, fully implementing this transition has proven challenging.

A number of studies have also highlighted informal relationships in Cuba as a form of participation and solidarity dynamics. Based on social networks, material exchanges, and mutual aid, these informal practices of popular participation have emerged as a crucial response to the chronic shortcomings of Cuba's National Health System (SNS), in particular since the beginning of the Special Period in the early 1990s. While not formally recognized, these unofficial coping mechanisms have become essential to the functioning of primary healthcare (Brotherton, 2012) and are tolerated by the state insofar as they help sustain the revolutionary project and manage a context of ongoing systemic crisis (Gobin, 2015).

During the COVID-19 pandemic, this dynamic was reinforced as residents activated community-based networks, to provide relational care alongside the state's traditional public health strategies (Burke, 2022). Nevertheless, the COVID-19 crisis ultimately reaffirmed the Cuban State's centralizing orientation in responding to crisis, as well as the population's strong reliance on state-led initiative and institutionalized forms of solidarity. In contrast, expressions of informal solidarity and individual responsibility were relegated to the background (Rodríguez González et al., 2024).
# 4. Material and methods

## 4.1. Study design

This study is part of a larger project titled "PrimaCoba - Primary Care facing the COVID-19 Pandemic in Cuba: Spatial Differences, Social Vulnerabilities, Experiences, and Lessons at a Global Level", a French-Cuban collaborative study that aims to better understand the role of Cuban primary healthcare in controlling the pandemic. Our team focused on social vulnerabilities, healthcare access, and community dynamics. To achieve this, we conducted an exploratory qualitative study in Playa, which allowed us to reflect on the anticipated methodological challenges and develop an appropriate protocol.

Prior to the research, the project was approved by the scientific committees of the leading institutions in Cuba, the National School of Public Health and the Institute of Tropical Medicine Pedro Kourí. The Ethics Review Board of the latter institution also provided ethical approval for this research (CEI-IPK 23-22). The ethical criteria for research involving humans, based on the updated Declaration of Helsinki (2013), were also taken into account. Informed consent was obtained from all participants, ensuring voluntary participation, the possibility of withdrawal from the study at any time without consequences, as well as anonymity, confidentiality of the information, and its use solely for scientific purposes. All the individuals and family units that participated in the study have been anonymized.

## 4.2. Study location

This study was conducted in and around Havana, the capital, and Cienfuegos, a province in the central region of Cuba. The Province of Havana is Cuba's most densely populated area, characterized by a service-oriented economy heavily reliant on tourism and international trade, and by the concentration of political and institutional power, including specialized healthcare facilities and research centers. In contrast, Cienfuegos represents a more peripheral territory, encompassing both urban and rural areas, with a less dense but dynamic healthcare network.

In the Havana area, we selected two peripheral municipalities, Playa and La Lisa. Both municipalities, located in the western part of the province, present distinct socioeconomic profiles, service concentrations, demographic characteristics, sociospatial conditions and living environments. Playa, relatively more affluent, has better infrastructure, commercial facilities, and housing conditions, as well as a higher proportion of elderly residents. It hosts key tourist sites, recreational spaces, restaurants, business institutions, and commercial zones, with good connectivity to the rest of the city. La Lisa, by contrast, is an area characterized by more residential land use, with a lower density of shops and services. Some neighborhoods are also marked by precarious, even unsanitary, housing and service conditions and the population tends to commute to other parts of the city for work (Remond Noa & Pérez Rodríguez, 2022).

In Cienfuegos, we focused our attention on the city-center municipality, particularly in neighborhoods surrounding university facilities, which served as key isolation centers and sources of human resources for the response, as well as the area of the Specialized Ambulatory Center, which served as a COVID-19 hospital and where a significant number of volunteers and healthcare professionals were mobilized. These communities are located in both central and peripheral areas of the city and are characterized by high population density and vulnerability, linked to environmental conditions and sociocultural practices. Moreover, during the epidemic period, these were the health areas that reported the highest number of cases.

Anchoring the study in these different locations enables the implementation of a comprehensive approach that highlights regional contrasts. Research on Cuba tends to disproportionately focus on Havana and the surrounding province, especially central and more touristic

districts, often leading to a generalization of its characteristics to the entire country. In our view, the incorporation of several sites across the national territory and within the capital city enhanced the accuracy of the analysis.

## 4.3. Study participants

For this study, we set out to understand the experiences of individuals participating in response initiatives who were not healthcare professionals.

Our primary focus was on the actions and experiences of individuals who, due to their roles and positions within the community, assumed tasks and responsibilities during the response. This includes actors recognized as neighborhood leaders, primarily those assigned political roles at the local level or actively involved in the Partido Comunista de Cuba (Communist Party of Cuba) or official mass organizations. As is common in Cuba, people held multiple affiliations with these organizations (Chaguaceda et al., 2012).

Additionally, we included individuals who, despite lacking official roles or responsibilities within political or mass organizations, were recognized figures in their neighborhoods. Their experience at the local level stemmed from their involvement in community development projects, past involvement in official responsibilities as leaders, and other initiatives.

We also gathered the experiences of individuals such as university students and public sector workers, two groups that were particularly encouraged to volunteer. The response plan included relocation for public-sector workers who were temporarily unemployed due to the shutdown of production and service sectors. Workers who accepted relocation were employed in activities such as food production, isolation centers, vacant positions in the public health system, epidemiological research, and care for vulnerable individuals in their neighborhoods. (Fundora Nevot, 2021).

In total, we conducted interviews with 10 men and 12 women engaged in the response process at the neighborhood level, within provincial healthcare facilities, or across both levels.

In addition, we conducted interviews with 10 families and 7 healthcare staff members in Havana.

## 4.4. Data collection

We conducted fieldwork over a period of four and a half months between June 2023 and March 2024.

Entry points to the field varied, depending on the role of the first informants such as family doctors, community leaders, university contacts, or provincial authorities. These entry points were also based on previous research experiences and contacts of some of the team researchers who were able to mobilize personal and professional networks. We adopted this particular non-probabilistic sampling strategy because we were exploring a sensitive issue i.e., vulnerability, both with respect to individuals and the healthcare system, in the context of a growing economic precarity in the country. Building on previously established contacts or past collaboration experiences, we were able to rely on a stronger foundation of trust, thus minimizing the non-response rate.

We conducted 11 interviews and 3 focus groups (in groups of 3 to 6 participants) with local actors, formal and informal leaders, workers, and students. 13 interviews with members of 10 families in Playa and La Lisa were conducted either individually or in small groups of two or more members. Regarding healthcare personnel, we conducted individual interviews with 4 family doctors and 2 epidemiologists from primary and tertiary care level in and around Havana (see Table 1).

Most interviews were conducted by at least two members of the research team. The simultaneous presence of both local and foreign team members helped build trust with participants, fostering a more open and collaborative atmosphere. This approach facilitated a deeper
<table><caption>**Table 1**
Overview of study participants.</caption><thead><tr><th></th><th>Playa</th><th>La Lisa</th><th>Cienfuegos</th><th>Total</th></tr></thead><tbody><tr><td>Families</td><td>5</td><td>5</td><td></td><td>10</td></tr><tr><td>Primary Healthcare staff</td><td>3</td><td>4</td><td></td><td>7</td></tr><tr><td>Local political leaders</td><td>1</td><td>1</td><td></td><td>2</td></tr><tr><td>Members of mass organizations (MO)</td><td>3</td><td>4</td><td></td><td>7</td></tr><tr><td>Informal community leaders</td><td></td><td>2</td><td></td><td>2</td></tr><tr><td>Public-sector workers relocated</td><td>1</td><td>1</td><td></td><td>2</td></tr><tr><td>University workers relocated</td><td></td><td></td><td>4</td><td>4</td></tr><tr><td>University students</td><td></td><td></td><td>5</td><td>5</td></tr></tbody></table>

understanding of community dynamics and encouraged participants to share their experiences more freely. Furthermore, conducting interviews collectively enabled the research team to compare perceptions and triangulate findings, thereby strengthening the methodological rigor and relevance of the study.

## 4.5. Data analysis

From the preliminary stages of fieldwork onward, data collected was continuously discussed and analyzed, with reflections taking place between each new interview. Debriefing sessions were held after every interview to review key insights and refine our approach. This ongoing analytical engagement allowed early insights to inform later interviews and supported theoretical sensitivity throughout the fieldwork process. Interviews transcripts were analyzed together with detailed field notes derived from participant observation and contextual documentation. Data were manually coded using inductive thematic analysis techniques. An initial coding framework was informed by macro-categories defined during the design of the interview guides—namely local vulnerabilities, healthcare access, implication in the response strategy, and relationships with primary healthcare (PHC) services. These preliminary categories, intended as sensitizing concepts rather than fixed analytical boundaries, were subsequently enriched and refined through an iterative inductive analysis process. Open coding was conducted to identify patterns, variations, and salient meanings through connecting (within) and categorizing (across) interviews strategies (Maxwell & Miller, 2008). Particular analytical attention was paid to the types of activities in which participants were involved, whether these engagements were based on prior experience or represented new forms of participation, and the social, institutional, and relational processes through which individuals became involved. Analytical memos were produced throughout the process to document interpretative decisions, emerging hypotheses, and reflexive considerations.

Additionally, preliminary findings were regularly discussed in interim project workshops and presented at academic conferences, providing opportunities for peer feedback and analytical validation by professionals with diverse backgrounds.

## 5. Results

Our study demonstrates that participation in the COVID-19 response in Cuba was a complex process that involved individuals as well as collectives. We identified two key ways in which people participated during the pandemic: 1) At the neighborhood level, community leaders, primary healthcare (PHC) staff, and residents worked together to coordinate local efforts. This form of grassroots collaboration played a crucial role in addressing immediate needs and organizing support networks. 2) In healthcare facilities such as isolation centers and hospitals, participation involved mostly university students and reassigned public-sector workers, stepping into roles that supported the increasingly strained healthcare system.

### 5.1. Connecting people and supplies

At the neighborhood level, one of the main tasks of community leaders was to ensure conditions that limited movement and, consequently, the risk of contagion among the population. This included efforts to educate and raise awareness among the population about protective measures—both hygienic and relating to social conduct. Their role also involved establishing strategies to mitigate the difficulties caused by confinement measures, particularly regarding the supply of food and essential goods. This was primarily achieved by coordinating the flow of people at state supply locations (bodegas), where all Cubans are entitled to receive state-supplied rations of food and basic goods through the *libreta* system and can buy other available products at a state-regulated price.

Another essential intervention was the implementation of home delivery services for food rations, particularly for people considered highly vulnerable or at high risk of severe outcomes if infected (e.g., the elderly, pregnant women, and individuals with chronic diseases), as well as those with mobility issues. Later in the pandemic, this service was also extended to infected individuals undergoing isolation at home.

> "There were cases where part of a family was hospitalized, and the rest were at home, vulnerable, with no one to bring them what they needed. [...] We would inform them what was available at the store, the cost, they would buy the items, and we delivered them to the door. This system helped a significant number of people." (Member of mass organization 1, Playa)

> "So, they isolated everyone, you see, everyone was isolated there, and we had a person in charge who brought us everything [...] because since I tested positive, we couldn't go out on the street to avoid infecting other people. (Family member 1, La Lisa)

In addition to the *libreta* and state-run stores, since the early 2000s, there has been a growing openness to private businesses, such as food shops and restaurants. To ensure distribution based on the population's needs, in Playa, where there was a greater number of private food businesses, community actors also took the initiative to establish connections with them to channel certain products to specific population categories. In other contexts, such as certain areas of La Lisa where basic facilities such as state-run food stores were scarce and had to serve a larger number of people, community leaders promoted the creation of new food distribution points to improve access to food and reduce crowding for residents.

Along with material and practical support, an important dimension of community actors' involvement was the moral and emotional support that their actions provided for residents, who could rely on their local leaders and volunteers to be mobilized for them.

> The neighborhood united, organized itself in such a way that the neighborhood organizations structured a support base for the families who were in quarantine, locked in their homes, and that's what helped, because yes, you can't go out, but you have the support of the neighborhood. [...] The support of the neighborhood was essential to ensure that families were confined but not isolated (Family member 2, Playa)

Participation in the response process resulted in social and moral rewards. The actors particularly emphasized the bonds formed with neighbors, as well as the gratitude received for the work done and the opportunity to contribute to the effort. New community bonds resulted from this engagement experience.

> "What makes me happy is when I hear people on the street, people I don't know, greeting me, which means I did a good job." (Member of mass organization 2, Playa)

> "I haven't had many particularly good or bad phases in my life, but this was one of the best times of my life ... everyone was involved, and I still miss those activities." (Member of mass organization 3, La Lisa)
Being actively involved in response efforts and social care actions enabled these actors to build and strengthen community bonds that have endured after the crisis. However, this came at a high cost. For community actors, despite their experience and long history of working in organization and community service, the intensity of the workload during the pandemic, which for many lasted for months, and the constant adaptation to changes, emergencies contingencies, and requests, led to significant pressure and exhaustion.

"I gave my heart and soul, and in the end, I ended up with a kidney infection and severe renal failure ... I think it was due to how much I gave." (Member of mass organization 3, La Lisa)

Especially in the case of women, this was compounded by the domestic and family caregiving burdens they had to continue managing.

"I had to take care of everything ... I had to be a doctor, a worker, a housewife, a mother—everything. It was very, very stressful." (Local political leader 2, La Lisa)

"Because we had to keep an eye on the children, the workload was double what it was when none of us were sick. [...] Also, when my dad was sick, I did a bit of work as a delegate — I went to the homes of some elderly people who couldn't go out and helped them because they didn't have any family. I would go and get things for them ..." (Woman, family member 3, Playa)

At the local level, community actors were pivotal in the response strategy, leveraging their organizational experience and extensive knowledge of their neighborhoods to implement and adapt general measures to local realities. Their involvement ensured that responses were closely aligned with specific social needs. However, the expectation that they would adequately address residents' difficulties placed an overwhelming burden of care on these actors, requiring them to assume a significant amount of responsibility throughout the pandemic.

## 5.2. Participating in medical care

As mentioned previously (see 3.2), the integration of non-healthcare actors in medical care activities is not a new phenomenon in Cuba and the response strategy to COVID-19 was no exception to this trend. On this occasion, these actors took on tasks like supporting primary healthcare staff at the local level and assisting in the management of COVID-19-specific facilities, such as isolation centers.

The collaboration between these volunteers and primary healthcare services, particularly with family doctors and nurses, materialized in different ways across the various territories studied. This depended on the history and previous experiences of collaboration between them, the dynamism and strength of local mass organizations, the doctors' experience in the neighborhoods, and the health personnel's needs and availability during the pandemic crisis.

"We [family doctor and nurse] wondered how we could manage to be in several places at the same time ... Impossible! [...] We [said] we can't do it alone, we need to find help somewhere because it's an extremely vast area. [...] The community leaders have helped us a lot, very, very much. [...] We've always had the help of the Health Brigades, the CDR ... since we started working here, 30 years ago. (PHC staff 1, Playa)

There was always a lot of cooperation [...] with the doctors and with everyone, all the community stakeholders, all the time. We've always had good communication because, for example, we organize blood drives here (Member of mass organization 1, Playa)

Generally, in areas where the relationship between PHC staff and community actors had a long-standing history, collaboration was more seamless. In other cases, where these ties were weaker due to limited organizational presence or frequent turnover of doctors in the neighborhood, coordination was more challenging.

Community actors also provided a crucial support in the logistical

organization of patient referral to specific facilities:

> Yes, I saw the delegates moving around with the doctor, trying to sort things out ... "Send the car [to transport sick people to the hospital or isolation centers]!" "Hey, the car didn't come to pick up this person, and I have them here infected, what do we do?" And they helped the doctor a lot. (Family member 3, La Lisa)

Given their territorial experience and the trust they enjoyed among neighbors, community leaders could be mobilized to accompany doctors in their outreach activities, thus enhancing compliance and trust regarding medical intervention and protocols.

"During the pandemic, the doctor had to come; no one else could leave or enter. [...] She would say, 'I need you to come up with me,' as she wouldn't go up alone. I had to accompany her because I was the one guarding the closed post." (Local political leader 2, La Lisa)

In areas with fewer healthcare resources (PHC staff and facilities like polyclinics and consultorios) relative to their territorial extension and population density, such as La Lisa, collaboration between community actors and health services expanded significantly. In these contexts, community members began to assume tasks traditionally carried out by medical professionals. The local healthcare personnel, redeployed to reinforce COVID-19 treatment centers such as hospitals and isolation centers, were, as several community leaders described, "overwhelmed."

Faced with this situation, community actors, under the supervision and guidance of doctors, began performing tasks such as conducting home visits to monitor patients and take their temperature. Although such responsibilities had been carried out by community members in previous health campaigns (e.g., during dengue outbreaks), in the context of COVID-19—and due to its specific mode of transmission—they were initially intended to remain the exclusive responsibility of healthcare personnel.

In La Ceiba, a [quarantine zone] was set up where, within a few blocks around it, 10 consecutive cases emerged. What did we, the community actors, do? [...] We were there from Monday to Monday, doing what needed to be done. There were two four-story buildings, and we had to go door-to-door taking people's temperatures. They gave us a thermometer and a form where we had to document the temperature of each person in the house, because no one was allowed to leave. No one other than us was allowed to enter, as it was a hotspot [...] The screening was carried out by the population itself. The doctors couldn't keep up, and the healthcare workers couldn't either, so it was us, the community agents, who took on the responsibility. (Member of mass organization 3, La Lisa)

Community actors also played a central role in the vaccination campaign starting in mid-2021. In fact, primary healthcare (PHC) personnel relied on their territorial and political organization to set up and manage patient flow.

"When they started setting up the vaccination centers, they immediately called us: 'Alright, we're going to set up the vaccination center. It's for people starting from such and such age ... We organized vaccination flows through the CDRs, by day, depending on age.' (Member of mass organization 1, Playa)

This collaboration with primary healthcare (PHC) staff, along with the screening, door-to-door, and delivery activities carried out by these actors, was not entirely new; it drew on memories and prior experiences of engagement in responses to previous epidemics. However, people felt that, in the context of COVID-19, the scale of the emergency and the intensity of the response efforts were unprecedented and much harder to bear.

"When the dengue outbreak happened, it was the same. We knew which houses were isolated and offered them help during the dengue epidemics. But it wasn't as intense or as widespread as it was with COVID." (Member of mass organization 1, Playa)
Volunteers were also recruited in healthcare facilities to support healthcare structures dedicated to containing or treating COVID-19. Experiences of people engaged in these spaces varied, depending on the kind of care provided in the institution or service they were allocated to (e.g., in intensive care unit in hospitals or isolation centers) and on the burden of cases at the precise period of the pandemic they were going through. Initially, their tasks focused on cleaning, disinfecting facilities, and distributing meals to hospitalized or isolated patients. However, their prolonged presence fostered close relationships with both patients and medical staff gradually extending their role to providing emotional support and reassurance:

"What we tried to do was alleviate them—not alleviate, but emotionally support them to continue with their tasks." (Public-sector worker relocated to isolation center 1, Playa)

"I think it was up to us to provide the human touch. The doctors were focused on their work, on medicine. [...] Patients in the rooms would call us instead of the doctors." (University worker relocated to isolation center 1, Cienfuegos)

As the health crisis intensified, with confirmed cases also placed in isolation centers, volunteers came into direct contact with sick individuals or performed similar tasks in critical areas such as intensive care units. Here, the impact was even greater, as most of them had no prior experience working in these kinds of structures or in crisis management contexts.

"At first, we thought it would just be about cleaning and other tasks ... but we had to improve the whole system along the way because no one knew what to do; we were all new to this." (University worker relocated to isolation center 1, Cienfuegos)

In these facilities as well, medical staff became overwhelmed, which led to the unexpected involvement of volunteers with no prior knowledge or training in medical care, taking on clinical tasks and responsibilities typically reserved for health professionals. Confronting these unprecedented situations often placed a heavy burden on them and proved to be a traumatic experience for many.

"Sometimes I went to deliver lunch or food, and a case would come up, and we had to help. You had to face the reality, and you never expected to be helping to open someone's mouth to insert a tube. That traumatizes anyone, like it did me." (public-sector worker relocated to an isolation center 2, La Lisa)

The close contact with contaminated people and materials, the prolonged stay in these spaces, and, as the health crisis intensified, the inability to ensure adequate protective equipment, in short, an overexposure to the risk of illness, was the source of considerable fear, both for themselves and the families they returned to after finishing their shifts.

"It was hard, even for us emotionally, it was hard. But when we got home, we had many fears too, about getting sick, bringing it to our families, to our children, to our neighbors ... we had many fears." (university worker relocated to isolation center 2, Cienfuegos)

Confronting death also represented an experience that tested emotional endurance.

"We had to undress the bodies and transport them to the door ... that was the most impactful thing for us ... when the hearse arrived ... it was me and my friend. I did it well, but I'm really afraid of death, and the first body I carried affected me because I started crying ... the shock of grabbing that black bag and putting it in the coffin." (University student, volunteer at hospital and isolation center 2, Cienfuegos)

"It was a beautiful experience, despite being traumatic [...] It was hard, it was very hard because there were children, elderly people, young people, there was everything. And sometimes ... We tried and they died, you

know? They died in your arms. That's tough." (public-sector worker relocated to an isolation center 2, La Lisa)

The initiative to open the doors of healthcare facilities such as hospitals and isolation centers to volunteers enabled healthcare personnel to receive the support they needed to focus on managing critical medical situations, while volunteers felt useful and recognized by the patients they were emotionally and materially supporting. However, having to perform clinical tasks in the field of resuscitation medicine or being confronted with death meant being assigned or having to assume caregiving responsibilities they had not anticipated and for which they were unprepared, forcing them to manage fears, tensions, and traumatic experiences on their own.

### 5.3. The dynamics of participation: navigating between top-down directives and local challenges

This massive and coordinated participation strategy was founded on a general and consolidated ethos of engagement and readiness in situations of crisis. In Cuban public discourse and informal discussions, concepts such as "commitment" and idioms such as "dar el paso al frente" [take a step forward] are commonplace, referring to collective dedication and the spirit of sacrifice crucial during times of adversity, particularly evident during the pandemic. For many people, committing to the nation's response was seen as a moral imperative, in line with the spirit of sacrifice and the sense of solidarity deeply ingrained in Cuban history and society.

"They asked each worker willing to work at the isolation center to take a step forward" (university worker relocated to isolation center 3, Cienfuegos)

"It was a process that instilled in us tremendous commitment, to the moment and to the country" (University worker relocated to isolation center 4, Cienfuegos)

However, the participation of the population in an infectious disease context represented a challenge for the healthcare system and the way of implementing and organizing participation in these special circumstances, even though Cuba had acquired a significant amount of experience in terms of mass mobilization in previous epidemic responses, as stated by an epidemiologist member of the PHC staff:

"I believe that community participation in the COVID epidemic is very different from community participation in a dengue epidemic, where the masses participate in the work. Here, the main directive was isolation. But there was community participation; in fact, all the people who were [community leaders] helped by bringing groceries to elderly people's homes, and all the young people who joined the isolation centers, as well as what was done in the communities in that respect ... Yes, there was participation, but in a different way. There was no volunteer work or large gatherings because the main measure was the isolation of people. (PHC staff 2, La Lisa)

Indeed, the response to COVID-19 followed a top-down dynamic, where popular participation was strictly structured by official channels. Directives from the highest levels of government were transmitted to provincial and then local administrations, which in turn mobilized and guided leaders of mass organizations. Volunteer involvement was consistently mediated by political authorities and formal leadership structures. Local governments, along with the local branches of the Communist Party (PCC), the Young Communist League (UJC), and the Federation of University Students (FEU), all organizations traditionally mobilized in crisis and emergency scenarios, played a key role in engaging community leaders and coordinating their initiatives.

"The directive to create the groups, organize things, and carry them out came down through the Party and the government." (Member of mass organization 1, Playa)
For their part, community leaders played a key role in mobilizing residents, especially young people, to participate in response efforts, both at the local level and within healthcare structures. They channelled personal intentions and willingness to help in an effort to address current needs and priorities as they attempted to maintain coordination and a general overview of localized initiatives:

> "Yes, there were people concerned about the elderly [...] all the coordination was done through the neighborhood representatives who reported to me as the delegate. They went to visit the elderly in the case of any problem." (Local political leader 1, Playa)

They also took a more directive approach by actively encouraging individuals to take part in support efforts, especially in particularly precarious contexts, where healthcare and formal community actors were already overwhelmed:

> "There was a lack of personnel to cover the isolation center. [...] A couple working at the cafeteria was approached, and they immediately closed up, gathered what they could, and left in a car to assist." (Member of mass organization 3, La Lisa)

> "The young man from across the street, [...] I told him: 'You have to do your part.' He was nervous, so I said: 'Have some chamomile tea, but you have to help me bring things to neighbors. And when I'm not around, it's up to you.'" (Local political leader 2, La Lisa)

Even for students, sustaining participation required persistent recruitment and persuasion. A student from Cienfuegos, assigned along with three others to manage an isolation center on a university campus, emphasized that youth mobilization was especially challenging and demanded extensive recruitment efforts:

> "In the first few hours, there was no one — just the four of us who started organizing everything in the isolation center [...] The FEU leaders began saying things like, 'Oh, I know a few people. We would call them and explain the situation, case by case.'

> It wasn't a matter of just putting out a call and having students come to us. No, no, no! Every single person who joined the team made an immense effort to recruit. It was always like a work group: 'Let's sit down and organize next week's team. How many people can you find? Let's talk to this person, and then that one ... '" (University student 2, Cienfuegos)

Local bottom-up, collective and creative initiatives emerged in parallel to formal and state driven actions, through which needs for medicines and food could be met, and care for the most vulnerable delivered, which played an active role in conditioning Cuba's pandemic response (Burke, 2022).

However, the main strategy primarily adopted of mobilizing participation through official channels sometimes excluded other community actors who led more informal yet impactful initiatives in their local areas, as well as the knowledge and contributions they could have brought to the response process.

For instance, this was evident in a constellation of actors concentrated around the community center (casa comunitaria) in one of the neighborhoods studied, who carried out community projects and organized meetings, workshops, and other activities involving the entire neighborhood. When the pandemic broke out, the community centers' director explained that this active network of local neighbors was sidelined as formal and political local leaders reclaimed the space for their own purposes:

> "During COVID, they set up the command post here without consulting us. [...] But if they had told us that this was going to happen, we could have been part of the solution." (Informal community leader 1, La Lisa)

However, this top-down coordination did not imply a standardization of practices. In each territory, local actors played a key role in adapting general directives and priorities to the specific characteristics and needs of their communities, for instance an aging population and

migrants in Playa, as well as informally documented residents in La Lisa:

> "In each place, things have to be adjusted to the situation there. Here in this district, our population is elderly, so we couldn't just provide care for 10 vulnerable people a day as the government suggested when in reality we had 30 daily." (Member of mass organization 2, Playa)

> "Not everyone here had their ration card registered at the local address, so the community members created a list of those without a local address to issue them a card so they could shop at the state stores." (Member of mass organization 3, La Lisa)

Participation in the COVID-19 response adhered to a structured, hierarchical framework. Within this system, the actions of community actors were directed by political authorities, and these actors themselves were responsible for coordinating public engagement in the tasks. This centralized approach often marginalized informal actors, thereby limiting grassroots initiatives. Nevertheless, it still allowed some flexibility, enabling local adaptation of measures based on specific needs and available resources.

## 6. Discussion

The Cuban response to COVID-19 provided new insights with regard to the tensions and contradictions inherent in combining a people-based strategy with a top-down management model. While the top-down/bottom-up dynamic is a long-established debate in public health, it takes on a different dimension in the Cuban context, where an extensive history of mass mobilization in health blurs this dichotomous categorization, as well as the usual divide between individual and state responsibilities.

A significant number of studies observe that territories with a history of participation and strong community dynamics were more effective in mobilizing support during the pandemic (Cubillo-Llanes et al., 2022; Duque Franco et al., 2020; Ferrer-Aracil et al., 2022). In Cuba, the existing organizational framework—comprising mass organizations, local political bodies, healthcare agents, and both formal and informal leaders, which structure ordinary social life and regularly mobilize the population—proved to be essential. The mobilization dynamics and participation channels during the response process mirrored historical patterns of mass mobilization. The readiness of people to respond to the emergency was possible “because the instruments that channelled these efforts were already in place” (Peñate Leiva et al., 2021).

This Cuban case illustrates how community participation cannot be reduced to a normative set of global health directives. Rather, it encompasses a broad range of social dynamics that are deeply rooted in the country's political and social history and embedded in everyday life, organizational structures, practices, and forms of socialization. The revolutionary ethos of self-sacrifice is key to understanding how the Cuban population responded to the pandemic. As part of the revolutionary process Cuban citizens “care for the state” as an inherent part of their social contract (Holbraad, 2021), in return of the state constant engagement in caring for them (Rodríguez González et al., 2024). Within a centralized and hierarchical institutional structure, participation in late revolutionary Cuba has been shaped as a way for people to be present when called upon to participate in activities—contributing and assisting, rather than leading autonomous initiatives aimed at fostering social change (Chaguaceda et al., 2012).

However, while this ability to mobilize human resources was crucial to achieving relatively positive health outcomes, COVID-19 response made it visible how Cuban forms of solidarity and engagement are still embedded in a vertical logic, which does not come without tensions and contradictions. Despite ongoing improvements and experimentation of new forms of participation in epidemic control programs, such as dengue, which have opened up more space for community actors to identify their needs and propose healthcare solutions (a bottom-up approach), the COVID-19 pandemic brought back the traditional and
well-known top-down model (Burke, 2022). A similar outcome was previously documented for empowerment strategies in dengue prevention in Cuba (Pérez et al., 2013).

In the meantime, this study shows that the response would not have been effective, or even possible, without local forms of adaptation and compromises with the official guidelines. The case of the COVID-19 pandemic shows how crucial it is for responses to be organized through local groups and leaders who best understand their communities and have existing links to residents (Wilkinson et al., 2020). This study demonstrates that, beyond the implementation of health measures, multiple forms of care at various scales were necessary for Cuba's pandemic response strategy to materialize. Cuba's response to the pandemic highlighted how community forms of solidarity and mobilization have been sensitive to multidimensional forms of vulnerability, far beyond medical needs, and, as a result, broadened the scope of the response itself. The role played by non-healthcare actors in their participation in the process was not merely to reinforce the application of these measures but to "fill the gaps," creating and ensuring the conditions for both the population and medical personnel to implement and adhere to the measures, despite the generalized and standardized public health directives. This study showed that local specificities, such as differences in socioeconomic levels, housing conditions, availability of services and infrastructure, as well as the distribution and workload of PHC staff, significantly impacted communities' ability to cope with the pandemic, but also influenced their capacity to comply with public health measures without exposing themselves to additional risks. Lessons from numerous disease outbreaks, including Ebola in West Africa, show that disease control measures can result in harm beyond the direct health threats and that, in many cases, the most severe shocks will be from control measures, not the disease (Wilkinson et al., 2020). Studies on community participation during COVID-19 highlight how formal and informal networks helped counteract inequalities worsened by top-down public health measures. The Cuban case confirms that certain measures, including those designed to mitigate the social and economic impact of the pandemic—such as work relocation policies, isolation measures and circulation restrictions—could, in lower-income families or more peripheral neighborhoods, place individuals in situations of enhanced vulnerability, increasing their exposure to risk. In those cases, a strong community network proved to be essential in helping to cope with these challenges.

Finally, people-based, participant response strategies to health crisis raise the question of the division of labor between lay people and professional medical staff. Our findings reinforce scholarship on grassroots responses to crisis, which highlights both their value and their remarkable inventive and adaptive capacity, but also the inherent limits of mutual aid and volunteerism when emergencies become prolonged (Carstensen et al., 2021).

In Cuba, the COVID-19 pandemic pushed the boundaries of community involvement into new areas. The civil population took on significant responsibilities and participated in practical initiatives in response to the crisis, engaging not only within their neighborhoods—through actions such as door-to-door health screenings and temperature checks—but also in newly established healthcare spaces, such as isolation centers, which required the mobilization of substantial human resources.

On the one hand, this reflects a core principle of community participation in healthcare: the capacity of individuals to actively engage in action, share responsibilities and knowledge with medical professionals, and thus play a proactive role rather than merely receiving assistance or passively following directives. This stands in contrast to the dominant, general tendency—also seen during the pandemic response—in which laypeople are viewed as out of place in emergency contexts (Scanlon et al., 2023). However, as the Cuban case illustrates, managing emergencies such as the COVID-19 pandemic through a community participation approach not only served to address

a complex web of needs and challenges, but also empowered individuals by involving them directly in the process, thereby strengthening both social and community bonds.

On the other hand, this level of community involvement in Cuba was unprecedented compared to previous public health campaigns, such as those for dengue control, resulting in an unexpected shift in responsibility to civilians. The overwhelming burden on medical staff in certain neighborhoods may have prompted unforeseen local adaptations where, due to territorial gaps in human and material resources and implementation understanding, civilians took on roles beyond the general guidelines and professional responsibilities. While Cuban political and healthcare institutions were deeply committed to coordinating the response—reorganizing the healthcare system, reallocating hospital spaces, adjusting patient flow, mobilizing human resources, and redistributing roles (Chávez Pérez et al., 2023)—, volunteers found themselves assuming tasks outside their original scope, including assisting with clinical procedures and addressing urgent patient needs, despite having no prior experience in such roles.

Moreover, Cuba's mobilization-based response strategy placed an additional care burden on individuals who were already heavily relied upon, such as women and local leaders. These individuals had to cope with a significant amount of stress, exposure to health risks, and an overwhelming workload, further complicating the social and emotional toll of the pandemic. These insights show that even in Cuba, where collective engagement and solidarity are embedded in political structure and everyday social practices, the COVID-19 experience exposed the challenges and fragility of sustaining citizen mobilization in a situation of protracted emergency.

## 7. Conclusion

Community participation in health and during sanitary crises is encouraged by international organizations such as WHO. The Cuban experience demonstrates that relying on community involvement to address healthcare emergencies challenges traditional debates in public health, such as the top-down versus bottom-up approaches, and the assumption that laypeople have no role to play in emergency response actions.

Cuba's response to the COVID-19 pandemic illustrates that engaging people and entrusting them with caregiving responsibilities during crises challenges the prevailing global health perspective that views individuals as passive subjects solely through a risk-management lens. This perspective is both medical and political, as it implies social and political assumptions about crisis management responsibilities, definitions of vulnerabilities, and responses to them. Furthermore, it raises questions about risk exposure and the collective and institutional responsibility to ensure safe conditions and support individuals taking on caregiving roles.

### CRediT authorship contribution statement

**Anna Pomaro:** Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. **Fanny Chabrol:** Writing – review & editing, Writing – original draft, Visualization, Project administration, Funding acquisition, Formal analysis. **Yadira Díaz Leal:** Writing – review & editing, Methodology, Investigation. **Nils Graber:** Writing – review & editing, Project administration, Funding acquisition, Formal analysis. **Vanesa Fernández Bereau:** Writing – review & editing, Resources, Investigation. **Dennis Pérez Chacón:** Writing – review & editing, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Data curation.

### Declaration of competing interest

The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.

Acknowledgements

This research has been financed in whole by Agence Nationale de la
Recherche (ANR) under the project ANR-22-CE36-0005-01. We express
our sincere gratitude to the family doctors, formal and informal com-
munity leaders, and residents of La Habana and Cienfuegos who
generously participated in this study. We are particularly indebted to
Maritza López McBean, Dr. Maria Lourdes de León Hernández, and Dr.
Vladimir Polo Diaz for their invaluable assistance in facilitating contact
with participants.

References

Anigstein, M. S., Watkins, L., Escobar, F. V., & Osorio-Parraguez, P. (2021). En medio de la crisis sanitaria y la crisis sociopolítica: Cuidados comunitarios y afrontamiento de las consecuencias de la pandemia de la covid-19 en Santiago de Chile. *Antipoda. Revista de Antropología y Arqueología, 45*, 53-77. https://doi.org/10.7440/antipoda45.2021.03

Beldarraín Chaple, E. (2013). Poliomyelitis and its elimination in Cuba: An historical overview. *MEDICC Review*, 15(2), 30-36. https://doi.org/10.37757/MR2013V15.N2.7

Beldarraín Chaple, E., Más Bermejo, P., Alfonso Sánchez, I. R., Vidal Ledo, M., Morales Suárez, I., Beldarraín Chaple, E., Más Bermejo, P., Alfonso Sánchez, I. R., Vidal Ledo, M., y Morales Suárez, I. (2022). Dicieíses meses de pandemia de COVID-19 en Cuba. *Info, 38*. http://scielo.sld.cu/scielo.php?script=sciabstract&pid=S1996-3521202200020005&lng=es&nrm=iso&tlng=es.

Beldarraín Chaple, E., Sánchez, I. R. A., Suárez, I. M., & García, F. D. (2020). Primer acercamiento histórico-epidemiológico a la COVID-19 en Cuba. *Anales de la Academia de Ciencias de Cuba, 10*(2). Article 2.

Briggs, C. L. (2011). "All Cubans are doctors!" news coverage of health and bioexceptionalism in Cuba. *Social Science & Medicine, 73*(7), 1037-1044. https://doi.org/10.1016/j.socscimed.2011.06.054

Bronfman, M., & Gleizer, M. (1994). Participación comunitaria: Necesidad, excusa o estrategia? O de qué hablamos cuando hablamos de participación comunitaria. *Cadernos de Saúde Pública, 10*(1). https://doi.org/10.1590/S0102-311X1994000100012

Brotherton, P. S. (2012). *Revolutionary medicine: Health and the body in Post-Soviet Cuba*. Duke University Press.

Burke, N. J. (Ed.). (2013). *Health travels: Cuban health(care) on and off the island*. University of California Medical Humanities Consortium.

Burke, N. J. (2022). Care in the time of COVID-19: Surveillance, creativity, and sociolismo in Cuba. In L. Manderson, N. J. Burke, & A. Wahlberg (Eds.), *Viral loads: Anthropologies of urgency in the time of COVID-19* (pp. 27–45). UCL Press. https://press.uchicago.edu/ucp/books/book/distributed/V/bo156860292.html.

Carstensen, N., Mudhar, M., & Munksgaard, F. S. (2021). ‘Let communities do their work’: The role of mutual aid and self-help groups in the COVID-19 pandemic response. *Disasters, 45*(S1). https://doi.org/10.1111/disa.12515

Chabrol, F., & Gaudillère, J.-P. (2023). *Introduction à la santé globale* (La Découverte). https://www.editionsladecouverte.fr/introduction_a_la_sante_globale-9782348081019.

Chaguaceda, A., Daubelcour, D., & González, L. (2012). Community participation in Cuba: Experiences from a popular council. *International Journal of Cuban Studies, 4*(3/4), 366-384.

Chávez Pérez, V. I., Reyes Cabrera, H. M., Delgado Acosta, H. M., & Duany Badell, L. E. (2023). Organización del enfrentamiento a la COVID-19 en una institución hospitalaria. Provincia Cienfuegos, 2020-2021. *MediSur, 21*(1), 99-107.

Cubillo-Llanes, J., García-Blanco, D., Benede-Azagra, B., Gallego-Diéguez, J., & Hernández García, M. (2022). Participación comunitaria: Aprendizajes de la COVID-19 para nuevas crisis. Informe SESPAS 2022. *Gaceta Sanitaria, 36*, S22-S25. https://doi.org/10.1016/j.gaceta.2022.02.011

Duque Franco, I., Ortiz, C., Samper, J., & Millan, G. (2020). Mapping repertoires of collective action facing the COVID-19 pandemic in informal settlements in Latin American cities. *Environment and Urbanization, 32*(2), 523-546. https://doi.org/10.1177/0956247820944823

Feinsilver, J. M. (1993). *Healing the masses: Cuban health politics at home and abroad*. University of California Press.

Fernández Salvador, C., Hill, M. D., Radhuber, I. M., & Román Brugnoli, J. A. (Eds.). (2024). *COVID-19 en América Latina: Solidaridad, desigualdades y espacios cotidianos*. *FLACSO Ecuador*.

Ferrer-Aracil, J., Giménez-Bertomeu, V.-M., & Cortés-Florín, E. M. (2022). Participación comunitaria durante la pandemia por COVID-19: Un estudio exploratorio en la provincia de Alicante. *Cuadernos de Trabajo Social, 35*(2), 307-317. https://doi.org/10.5209/cuts.79403

Fundora Nevot, G. (2021). Gestión de empleo y seguridad social en contexto de pandemia: Las certezas y desasosiegos de la experiencia cubana. In M. del C. Zabala Argüelles, M. F. Ortega Marte, G. E. Fundora Nevot, M. Bosch Carcuro, A. Fernández Gil, D. Echevarría León, R. Gómez Ramírez, A. Balbuena García, Y. Rivero Baxter, M. Cantisano Rojas, D. Pérez Chacón, Y. Hernández Barrios, G. Basile, P. Polanco, &

J. Japa Rodríguez (Eds.), *Enfrentando la COVID-19 en el Caribe: Experiencias en República Dominicana y Cuba* (pp. 79-115). *FLACSO Cuba, Friedrich-Ebert-Stiftung*.

Galbán-García, E., & Más-Bermejo, P. (2021). COVID-19 in Cuba: Assessing the national response. *MEDICC Review, 22*, 29-34. https://doi.org/10.37757/MR2020.V22.N4.5

Gobin, E. (2015). L'émergence du New Age dans la Cuba postsoviétique. Changement social, médecines alternatives et circulations religieuses. *Autrepart, 74-75*(2-3), 137-156. https://doi.org/10.3917/autr.074.0137

Gorry, C. (2022). Vaccines and public trust: Containing COVID-19 in Cuba verena muzigonzález PhD DSc director of clinical research, genetic engineering and biotechnology center. *MEDICC Review, 24*, 9-13. https://doi.org/10.37757/mr2022.v24.n1.11

Graber, N. (2018). An alternative imaginary of community engagement: State, cancer biotechnology and the ethos of primary healthcare in Cuba. *Critical Public Health, 28*, 1-12. https://doi.org/10.1080/09581596.2018.1440071

Guzmán Tirado, M. G. (2012). Treinta años después de la epidemia cubana de dengue hemorrágico en 1981. *Revista Cubana de Medicina Tropical, 64*(1), 5-14.

Holbraad, M. (2021). The house of spirits: Care and the revolutionary state in Cuba. *The Cambridge Journal of Anthropology, 39*(2), 112-127. https://doi.org/10.3167/cja.2021.390208

Iatridis, D. S. (1990). Cuba's health care policy: Prevention and active community participation. *Social Work, 35*(1), 29-35. https://doi.org/10.1093/sw/35.1.29

Kourí, G., Guzmán, M. G., Valdés, L., Carbonel, I., del Rosario, D., Vazquez, S., Laferté, J., Delgado, J., & Cabrera, M. V. (1998). Reemergence of dengue in Cuba: A 1997 epidemic in Santiago de Cuba. *Emerging Infectious Diseases, 4*(1), 89-92.

Loewenson, R., Colvin, C. J., Szabzon, F., Das, S., Khanna, R., Coelho, V. S. P., Gansane, Z., Yao, S., Asibu, W. D., Rome, N., & Nolan, E. (2021). Beyond command and control: A rapid review of meaningful community-engaged responses to COVID-19. *Global Public Health, 16*(8-9), 1439-1453. https://doi.org/10.1080/17441692.2021.1900316

Lyteris, C., & Poleykett, B. (2018). The anthropology of epidemic control: Technologies and materialities. *Medical Anthropology, 37*(6), 433-441. https://doi.org/10.1080/10459740.2018.1484740

Manderson, L., & Burke, N. J. (Eds.). (2025). *Covid's chronicities. From urgency to stasis in a pandemic era*. UCL Press.

Marston, C., Renedo, A., & Miles, S. (2020). Community participation is crucial in a pandemic. *The Lancet, 395*(10238), 1676-1678. https://doi.org/10.1016/S0140-6736(20)31054-0

Mas Bermejo, P., Sánchez Valdés, L., Somarriba López, L., Valdivia Onega, N. C., Vidal Ledo, M. J., Alfonso Sánchez, I., Seu Jo, A., Almeida Cruz, Y., & Morales Ojeda, R. (2020). Equidad y respuesta del Sistema Nacional de Salud de Cuba ante la COVID-19. *Revista Panamericana de Salud Pública, 44*, Article e138. https://doi.org/10.2663/RPSP.2020.138

Maxwell, J. A., & Miller, B. A. (2008). Categorizing and connecting strategies in qualitative data analysis. In S. N. Hesse-Biber, & P. Leavy (Eds.), *Handbook of emergent methods* (pp. 461-478). Guilford Press.

Mbaye, E. M., Kone, S., Kà, O., & Mboup, S. (2017). Évolution de l'implication des communautés dans la riposte à Ebola. *Santé Publique, 29*(4), 487-496. https://doi.org/10.3917/spub.174.0487

McDowell, A., Ruault, L., Fiorilli, O., & Pordié, L. (2022). Localization in the global. In J.-P. Gaudillière, A. McDowell, C. Lang, & C. Beaudevin (Eds.), *Global health for all: Knowledge, politics, and practices* (pp. 29-55).

Morgan, L. M. (1993). *Community participation in health: The politics of primary care in Costa Rica*. Cambridge University Press. https://doi.org/10.1017/CBO9780511558092

Peléaz, O., Guzmán, M. G., Kourí, G., Pérez, R., Martín, J. L. S., Vázquez, S., Rosario, D., Mora, R., Quintana, I., Bisset, J., Cancio, R., Masa, A. M., Castro, D., González, A., Avila, L. C., Rodríguez, R., Alvarez, M., Pelegrino, J. L., Bernardo, L., & Prado, I. (2004). Dengue 3 Epidemic, Havana, 2001. *Emerging Infectious Diseases Journal - CDC, 10*(4), 719-722. https://doi.org/10.3201/eid1004.030271

Pénate Leiva, A. I., Armas Pedraza, G., Muñoz Campos, M. R., Pérez, D. D., & Porro Mendoza, S. (2021). Cuba: Participación social y prácticas juveniles en tiempos de COVID-19. *Revista Estudios Del Desarrollo Social: Cuba y América Latina, 9*(1). http://scielo.sld.cu/scielo.php?script=sciabstract&pid=S2308-01322021000100002&lng=es&nrm=iso&tlng=es.

Pérez Chacón, D., & Hernández Barrios, Y. (2021). SARS-CoV-2 y COVID-19. Una lectura a la respuesta sanitaria cubana. In M. del C. Zabala Argüelles, M. F. Ortega Marte, G. E. Fundora Nevot, M. Bosch Carcuro, A. Fernández Gil, D. Echevarría León, R. Gómez Ramírez, A. Balbuena García, Y. Rivero Baxter, M. Cantisano Rojas, D. Pérez Chacón, Y. Hernández Barrios, G. Basile, P. Polanco, & J. Japa Rodríguez (Eds.), *Enfrentando la COVID-19 en el Caribe: Experiencias en República Dominicana y Cuba* (pp. 323-374). *FLACSO Cuba, Friedrich-Ebert-Stiftung*.

Pérez, D., Lefèvre, P., Castro, M., Toledo, M. E., Zamora, G., Bonet, M., & Van Der Stuyft, P. (2013). Diffusion of community empowerment strategies for Aedes aegypti control in Cuba: A muddling through experience. *Social Science & Medicine, 84*, 44-52. https://doi.org/10.1016/j.socscimed.2013.02.003

Pérez Riverol, A. (2020). The Cuban strategy for combating COVID-19. *MEDICC Review, 22*(3), 64-68.

Prince, R. (2019). Pandemic publics. How epidemics transform social and political collectives of public health. In A. H. Kelly, F. Keck, & C. Lyteris (Eds.), *The anthropology of epidemics*. Routledge. https://doi.org/10.4324/9780429461897.

Ramírez, R. (2005). State and civil society in the barrios of Havana, Cuba: The case of Pogolotti. *Environment and Urbanization, 17*(1), 147-170. https://doi.org/10.1177/095624780501700115

Remond Noa, R., & Pérez Rodríguez, N. (Eds.). (2022). *La Habana: Atlas de la COVID-19. Editorial Universidad de La Habana*.
Reynolds, L., & Sariola, S. (2018). The ethics and politics of community engagement in global health research. *Critical Public Health, 28*(3), 257–268. https://doi.org/10.1080/09581596.2018.1449598

Rifkin, S. B. (1996). Paradigms lost: Toward a new understanding of community participation in health programmes. *Acta Tropica, 61*(2), 79–92. https://doi.org/10.1016/0001-706x(95)00105-n

Rodríguez González, D. R., Fabré Machado, I., Fernández Castillo, E., Vizcaíno Escobar, A. E., & Ruiz y Alegna Cruz Ruiz, A. L. (2024). Solidaridad de Estado y solidaridad pandémica ante la COVID-19: El caso cubano. In C. Fernández Salvador, M. D. Hill, I. M. Radhuber, & J. A. Román Brugnoli (Eds.), *COVID-19 en América Latina: Solidaridad, desigualdades y espacios cotidianos* (pp. 129–154). FLACSO Ecuador.

Rojas Ochoa, F. (2005). La atención primaria de salud en Cuba, 1959-1984. *Revista Cubana de Salud Pública, 31*(2), 0-0.

Sánchez, R. (2020). Cuba: Une histoire longue de la « nation soignante. La Revue du Praticien, 70*(10). https://www.larevuedupraticien.fr/article/cuba-une-histoire-longue-de-la-nation-soignante.

Sanchez, L., Pérez Chacón, D., Cruz, G., Castro, M., Kourí, G., Shkedy, Z., Vanlerberghe, V., & Van der Stuyft, P. (2009). Intersectoral coordination, community empowerment and dengue prevention: Six years of controlled interventions in Playa Municipality, Havana, Cuba. *Tropical Medicine and International Health: TM & IH, 14*(11), 1356–1364. https://doi.org/10.1111/j.1365-3156.2009.02379.x

Scanlon, J., Helsoot, I., & Groenendaal, J. (2023). Putting it all together: Integrating ordinary people into emergency response. *International Journal of Mass Emergencies and Disasters, 32*(1), 43–63. https://doi.org/10.1177/028072701403200103

Soriano Fernández, A. F., Dilla Alfonso, H., & Castro Flores, M. (1999). Movimientos Comunitarios En Cuba: Un Análisis Comparativo. *Estudios Sociológicos, 17*(51), 857–884.

Teorell, J. (2006). Political participation and three theories of democracy: A research inventory and agenda. *European Journal of Political Research, 45*(5), 787–810. https://doi.org/10.1111/j.1475-6765.2006.00636.x

Uriarte, M. (2002). *Cuba. La política social en la encrucijada: Manteniendo las prioridades, transformando la práctica. Un informe de Oxfam América*. Universidad de Massachusetts.

Wilkinson, A., Ali, H., Bedford, J., Boonyabancha, S., Connolly, C., Conteh, A., Dean, L., Decorte, F., Dercon, B., Dias, S., Dodman, D., Duijsens, R., D'Urzo, S., Eamer, G., Earle, L., Gupte, J., Frediani, A. A., Hasan, A., Hawkins, K., ... Whittaker, L. (2020). Local response in health emergencies: Key considerations for addressing the COVID-19 pandemic in informal urban settlements. *Environment and Urbanization, 32*(2), 503–522. https://doi.org/10.1177/0956247820922843

Wilkinson, A., Parker, M., Martineau, F., & Leach, M. (2017). Engaging “communities”: Anthropological insights from the West African Ebola epidemic. *Philosophical Transactions of the Royal Society of London - Series B: Biological Sciences, 372*(1721), Article 20160305. https://doi.org/10.1098/rstb.2016.0305

World Health Organization (WHO) & United Nations Children's Fund (UNICEF). (1978). *Declaration of Alma-Ata: International conference on primary health care, Alma-Ata, USSR, 6-12 September 1978*. World Health Organization. https://www.who.int/publi cations/almaataDeclaration_en.pdf.