The two presidents drove out 10,000 Cuban doctors and nurses. They defunded the region's leading health agency. They wrongly pushed hydroxychloroquine as a cure.
The coronavirus was gathering lethal speed when President Donald Trump met his Brazilian counterpart, Jair Bolsonaro, on March 7 for dinner at Mar-a-Lago. Bolsonaro had cancelled trips that week to Italy, Poland and Hungary, and Brazil's health minister had urged him to stay away from Florida, too.
But Bolsonaro insisted, eager to burnish his image as the "Trump of the Tropics." His grinning aides posed at the president's resort in green "Make Brazil Great Again" hats. Trump declared he was "not concerned at all" before walking Bolsonaro around the club shaking hands.
Twenty-two people in Bolsonaro's delegation tested positive for the virus after returning to Brazil, yet he was not alarmed. Trump had shared a cure, Bolsonaro told advisers: a box of the anti-malaria drug hydroxychloroquine, the unproven treatment that Trump was then promoting as a remedy for Covid-19.
"He said the trip was wonderful, that they had a great time, that life was normal at Mar-a-Lago, everything was cured, and that hydroxychloroquine was the medicine that was supposed to be used," recalled the health minister, Luiz Henrique Mandetta, who was fired by Bolsonaro the next month for opposing reliance on the drug.
"From that time on, it was very hard to get him to take the science seriously."
The Mar-a-Lago dinner, which would become infamous for spreading infection, cemented a partnership between Trump and Bolsonaro rooted in a shared disregard for the virus. But even before the dinner, the two presidents had waged an ideological campaign that would undermine Latin America's ability to respond to Covid-19.
Together, the two men, fierce opponents of Latin America's leftists, took aim at Cuba's great pride: the doctors it sends around the world. Trump and Bolsonaro drove 10,000 Cuban doctors and nurses out of impoverished areas of Brazil, Ecuador, Bolivia and El Salvador. Many left without being replaced only months before the pandemic arrived.
Then, the two leaders attacked the international agency most capable of fighting the virus — the Pan-American Health Organization, or PAHO — citing its involvement with the Cuban medical program. With help from Bolsonaro, Trump nearly bankrupted the agency by withholding promised funding at the height of the outbreak, to an extent not previously disclosed.
And with help from Trump, Bolsonaro has made hydroxychloroquine the centerpiece of Brazil's pandemic response, despite a medical consensus that the drug is ineffective and even dangerous. The Food and Drug Administration warned last April against most uses of the drug to treat Covid-19. A month later, Trump announced after a phone call with Bolsonaro that the United States would send Brazil 2 million doses.
Weak health systems and overcrowded cities made Latin America inherently vulnerable. But by driving out doctors, blocking assistance, and pushing false cures, Trump and Bolsonaro made a bad situation worse, dismantling defences.
Now Latin America, with a third of the world's deaths, has suffered more acutely from Covid-19 than any other region.
The two most powerful leaders in the Americas, Trump and Bolsonaro are both ardent nationalists defiant of mainstream science. Both have put economic growth and short-term politics ahead of public health warnings. Both are deeply hostile to the region's leftist governments — especially in Cuba, a cause that helps Trump with Cuban American voters in the swing state of Florida.
"In their zeal to get rid of the Cuban doctors, the Trump administration has punished every country in the hemisphere, and without question that has meant more COVID cases, and more Covid deaths," said Mark L. Schneider, a former head of strategic planning for PAHO who was a State Department official in the Clinton administration. "It is outrageous."
Smaller, less powerful countries like Ecuador felt the pain. Ecuador acceded to US pressure and sent home nearly 400 Cuban health care workers shortly before the pandemic. Then the country also suffered from the Trump administration's freeze on funding for the health organization, which hampered its ability to provide emergency supplies and technical support.
"No one from the Pan-American Health Organization was here, and we felt their absence," said Dr. Washington Alemán, a senior infectious disease specialist and a former deputy health minister in Ecuador, who diagnosed the country's first confirmed case of Covid-19. "The support was not like it used to be in previous years, in previous epidemics."
Previous Republican and Democratic administrations have almost all regarded the public health of Latin America as of urgent national interest, because infectious diseases can spread easily between South and North America.
White House officials say the administration withheld payments from the health organization to demand transparency. They note that the United States helped the region in other ways, by donating tens of millions of dollars through organizations like the World Food Program, UNICEF and the Red Cross. Over the summer, Washington sent hundreds of excess ventilators directly to government health systems.
But public health experts say the Pan-American Health Organization — with offices inside every health ministry and nearly 120 years of experience tackling epidemics — was uniquely positioned to confront Covid-19. Even some critics of the Cuban program say that punishing the health agency sabotaged that effort.
"PAHO did not have the tools and they didn't have the money," said Mandetta, the former Brazilian health minister who worked with Bolsonaro to expel the Cubans. "PAHO couldn't expand the way that they needed to, and in Ecuador, in Bolivia, you had people dying in their homes and bodies left outside in the streets because of the lack of assistance."
How that happened is the story of a political battle that shifted among many fronts, from Brasília to Miami to Washington. It left scars from villages in the Amazon basin to the slums of the Ecuadorean city of Guayaquil.
'Bread from heaven'
Jair Bolsonaro roared into power in Brazil in October 2018, styling himself as a Trumpian populist, speaking favourably of "dictatorship," and accusing his country's left-leaning establishment of taking lessons from communist Cuba. He promised to expel more than 8,000 Cuban medical workers.
A predecessor had invited the Cubans five years earlier to help care for more than 60 million people, mostly in small communities in the Amazon basin, many of whom had never before seen a doctor. Academic studies reported high levels of patient satisfaction and reduced infant mortality rates. PAHO oversaw the Cuban doctors in Brazil and promoted their work as a model; the Obama administration raised no objection.
For decades, Cuba has sent medical workers to fill holes in health systems in Latin America and beyond. Cuba paid the doctors as much as US$900 ($1,300) a month compared with the US$50 ($75) a month they might earn at home. But Havana charged their host governments much more — about US$4,300 ($6,420) a month for each doctor in Brazil — and pocketed the difference. Cuba called the program humanitarian; critics, noting that Cuba limited the freedom of the doctors, called it forced labor and human trafficking.
During Bolsonaro's fiery election campaign, a newspaper disclosed 6-year-old diplomatic cables suggesting that Brazilian officials had routed payments for the program through the health organization in part to avoid a debate in the Brazilian Congress over dealing with Cuba.
Bolsonaro accused the health organization of abetting "modern-day slavery" and vowed to get rid of the doctors. Cuba recalled them even before he was sworn in.
Roughly 10,460km away, in Miami, Tony Costa saw a rare opportunity.
An 80-year-old veteran of the aborted Bay of Pigs invasion, Costa has spent decades working to topple the communist leadership in Havana. When he connected the allegations of Cuban forced labor with the Washington-based PAHO, he knew he had something that would captivate Congress and the White House.
"This is like bread from heaven!" he recalled thinking.
Costa soon discovered Ramona Matos Rodríguez, a Cuban doctor who had defected to Miami from a mission to Brazil, and helped her become the lead plaintiff in a lawsuit accusing PAHO of forced labor and human trafficking.
In a court filing, lawyers for the organization said the allegations were "grossly inaccurate" and "bear almost no resemblance to reality." Experts say the lawsuit is at best a long shot, but, in politics, it made an impact.
Without waiting for a court ruling, Costa, a founder of the Miami-based Foundation for Human Rights in Cuba, rushed the lawsuit to the attention of powerful friends in Congress and the White House. "It is just despicable what they are doing to these poor doctors," Senator Rick Scott, R-Fla., said in an interview last month.
Citing the accusations, the State Department pressured Ecuador, Bolivia and El Salvador until they expelled more than 1,000 Cuban medical workers last year.
But the bigger blows hit the Pan-American Health Organization.
It is often known as the regional arm of the World Health Organization, yet it is decades older and receives much more funding from member states. Public-health experts credit the agency with eradicating smallpox, polio and measles from Latin America long before they were eliminated from Africa and Asia.
The Trump administration focused intensely on the organisation's ties to Cuba, even though its involvement with the Cuban doctors had ended about a year earlier, when they left Brazil. The US stopped paying its annual dues of US$110 million, more than half the agency's core budget. Bolsonaro's government also froze payment of its US$24 million in dues.
Bolsonaro and his staff refused to comment for this article. John Ullyot, a National Security Council spokesperson, defended the US funding cutoff as an important step "to demand accountability from all international health organizations that depend on American taxpayer resources."
By the end of 2019, the agency faced a funding crisis. It had sharply reduced international travel, frozen hiring and cut contracts for the medical consultants who do most of its hands-on work.
Within six weeks, Covid-19 began seeping into Latin America.
Bodies on the streets
Perched on Ecuador's southern coast, Guayaquil is a busy port city surrounded by hillsides covered in slums.
Bella Lamilla, 70, arrived from Spain on February 15, to visit her nearby birthplace. But while there, she developed pneumonia.
Ecuador had no labs with the supplies or capacity to test for the coronavirus, but Lamilla's family happened to take her to a private clinic that employs Alemán, the former deputy health minister. He used his contacts to get a sample sent to the Centers for Disease Control and Prevention in Atlanta.
She became Ecuador's first confirmed case on the night of February 29. Within two weeks, every intensive care unit in the city was overwhelmed.
Doctors in Guayaquil say that more hands-on advice from PAHO might have helped detect the virus much sooner, before it had penetrated the city so deeply.
Then ill-informed Health Ministry officials and local doctors compounded the crisis with a basic error: The ministry recommended cheap coronavirus antibody tests rather than more difficult and expensive genetic tests.
The antibody tests yielded false negatives at the point when patients were most contagious, leading them to unknowingly spread the virus.
"It was ignorance, absolutely," said Juan Carlos Zevallos, a US-trained epidemiologist appointed in late March as health minister.
More direct support from PAHO consultants "could have prevented not only that mistake but many others," Alemán said.
For many families, those mistakes meant heartbreak. In July, Patricio Carrillo, 70, visited a doctor at his local health center near Quito, the national capital. He had received a negative antibody test and was given penicillin for pharyngitis, his son recalled.
"I have nothing more than the flu," Carillo reassured his family in a hoarse voice message.
Days later, he was dead from Covid-19.
At the main public hospital in Guayaquil, Paola Vélez Solorzano, 38, an infectious diseases specialist, had urged administrators as early as February to prepare a 29-bed coronavirus isolation ward. She commandeered 900 disposable biohazard suits mistakenly ordered for maintenance workers.
But when the pandemic arrived, her preparations were "like nothing," she said. So many people died that doctors had to step over bodies piled on the floor of the morgue. "Wherever you stood, it smelled like rotting flesh," she said.
Her colleague Galo Martínez, 34, recalled gazing out the window of the intensive care unit. "All I could see was crowds of people crying out for help," he said, shaking his head.
Without enough protective equipment, half the Health Ministry employees in Guayaquil fell sick, doctors said. More than 130 doctors died.
"We did not even have masks," Zevallos, the health minister, said.
During past outbreaks, local doctors credit PAHO with procuring supplies or rushing in skilled consultants to provide face-to-face technical help to laboratories and hospitals.
The agency's officials say that this time they faced special challenges. Testing materials and protective equipment became scarce globally. By late March, shutdowns of commercial air travel made it difficult to deploy experts.
But the funding crisis caused by Trump's freeze also loomed large, even as leaders tried to compensate by shifting resources to prioritise Covid-19 response.
Jarbas Barbosa da Silva Jr., the agency's assistant director, acknowledged that the impact of the US funding freeze was "severe" but argued that its consequences were hard to assess precisely. By spring, he said, the freeze was not yet "a life-or-death situation" for the organization, and even with fuller funding the travel shutdown would have limited it to offering virtual training sessions.
But speaking on condition of anonymity to avoid angering the Trump administration, other senior officials said more money would have enabled the agency to provide more hands-on help, sooner. Regional meetings that might have discussed efforts to tackle the virus were instead consumed by the funding crisis.
"Will it close its headquarters? All these discussions took up the agenda," said Felipe Carvalho, who follows the organization at the nonprofit Doctors Without Borders.
On the ground in Ecuador, Carmina Pinargote felt the difference. A veteran Health Ministry official on the northern coast, Pinargote recalled how PAHO immediately sent 15 epidemiologists and technical experts after an earthquake in 2016. This year, she said, only one agency consultant arrived in her region.
"We have not seen the same intensity," she said.
The forced departure of 400 Cuban medical workers did not help, either. At the Martha de Roldós Health Center on the outskirts of Guayaquil, the director, Hugo Duarte, said two Cubans had to leave months before the pandemic.
Ecuadorean doctors would have been just as good, he said, if the Health Ministry had paid enough to fill the vacancies. But the loss had strained the clinic, especially when he was sickened for weeks.
"People were falling dead on the sidewalk, just outside the health center," Duarte said.
Dubious medical advice
As the epidemic was exploding in Ecuador, Bolsonaro returned to Brazil from Mar-a-Lago. He quickly summoned Nise Yamaguchi, a São Paulo oncologist who had become a prominent champion of hydroxychloroquine.
Yamaguchi told the president that the outbreak left no time for the kind of clinical trials other doctors were waiting for.
Brazil had been known for one of the strongest public health systems in Latin America for fighting infectious diseases. But when two health ministers refused to support the drug, Bolsonaro replaced them with a loyal military officer, while Yamaguchi became his most trusted adviser.
In an interview, she said Trump's donation of 2 million doses had made Brazil's reliance on the medicine possible.
"It was very important because we had a worldwide shortage of hydroxychloroquine at the time," Yamaguchi said.
"God is Brazilian, the cure is right here!" Bolsonaro exclaimed to supporters in late March.
Ignoring a medical consensus, Brazil's Health Ministry still provides free hydroxychloroquine to anyone with Covid-19. And critics say Bolsonaro's promotion of the drug, coupled with his refusal to wear a mask or socially distance, has undermined public health.
"People say, 'If I become sick I can go out and get hydroxychloroquine like the president,'" said Julio Croda, an infectious disease specialist and former Health Ministry official. "People think they can live normal lives and they don't need to do any prevention."
Brazil has suffered more than 157,000 deaths from Covid-19, a total second only to the United States.
Indigenous communities in the remote Amazon basin, which lost 8,000 Cuban medical workers, have been hardest hit. Compared with other Brazilians in the Amazon basin, Indigenous people have been 10 times as likely to contract the virus, according to the Pan-American Health Organization.
The Cubans had been a critical source of health advice and treatment, often providing the only primary care for hundreds of miles, said Luiza Garnelo, a doctor and anthropologist based in Manaus for the Flocruz foundation.
Without the Cubans, she said, "there are no professionals to diagnose."
Beltway politics
When the pandemic hit, the Pan-American Health Organization began raising US$92 million to send out infectious disease experts and critical supplies. The goal was later raised to US$200 million.
Washington would ordinarily be one of the largest contributors. But the main donor agency, the United States Agency for International Development, or USAID, is now headed by Ambassador John Barsa, a Cuban American critic of Havana who participated in a 2019 news conference to publicise the lawsuit against the Pan-American Health Organization.
This time, the United States offered almost no new money.
By May, the Pan-American agency's board warned in an internal report of a looming crisis.
Referring to the organization by its alternate name — the Pan-American Sanitary Bureau, or PASB — the report said that the Trump administration's withholding of funds was "significantly reducing the capacity of the PASB to provide technical cooperation to its member states and entailing the release of many critical short-term staff members and contingent workers."
At the end of the month, Trump announced that the United States was withdrawing from the World Health Organization and the administration temporarily froze other grants to the Pan-American agency.
USAID made one exception: It added US$3.9 million in grants related to Venezuela, according to officials. That spending is part of the administration's efforts to overturn the country's leftist government. (The CDC also sent US$900,000.)
Otherwise, the campaign against the agency only escalated. "PAHO must explain how it came to be the middleman in a scheme to exploit Cuban medical workers," Secretary of State Mike Pompeo declared on June 10.
It took funding from Canada for the health organization to send some protective equipment to Ecuador, the first time it had done so for any country. President Lenín Moreno greeted the June 25 shipment at the airport.
Finally, under congressional pressure, the Trump administration on July 15 unblocked US$65 million, staving off insolvency for the organization. Pompeo said it had agreed to an outside investigation of the Cuban doctors program, and other funds were unfrozen a short time later, after a roughly three-month suspension.
"PAHO is uniquely positioned to perform Covid-19 response in certain countries where there is no viable alternative," a State Department official wrote on July 15 in an email informing congressional staff of the payment.
Aftermath
Catching the virus did nothing to change either president's outlook. Bolsonaro, 65, was infected in July and suffered only mild symptoms. He celebrated his recovery with a motorcycle ride and stands by his embrace of hydroxychloroquine.
Trump, 74, quietly stopped promoting that drug. When he was briefly hospitalised with Covid-19 this month, he received other medicines. He began describing some of those as miracle cures and returned to dismissing the virus.
"People are tired of Covid," he said this week on a campaign conference call. "People are saying: 'Whatever. Just leave us alone.'"
PAHO officials say they have raised only US$46.5 million from member states toward their US$200 million goal to combat the virus.
The Trump administration continues to pressure other countries to expel Cuban doctors. An organization of Caribbean states this summer condemned the White House for threatening to "blacklist" those that refuse.
Other countries known for their sophisticated health systems have welcomed Cuban help. A group of 40 Cuban medical workers went to Turin in Italy last spring to help fight the pandemic, said Carlo Picco, who leads health services in the city.
"The Cubans were a success story for us," he said.
Written by: David D. Kirkpatrick and José María León Cabrera
Photographs by: Anna Moneymaker, Daniel Berehulak, T.J. Kikpatrick, Victor Moriyama, Tyler Hicks, Dado Galdieri and Adriana Loureiro Fernandez
© 2020 THE NEW YORK TIMES