CMAJ/JAMC Editorial
Éditorial

 

The US attack on Cuba's health

Anthony F. Kirkpatrick, MD, PhD

CMAJ 1997;157:281-4

[ résumé ]

Dr. Kirkpatrick is from the College of Medicine, University of South Florida, Tampa, Fla.

Reprint requests to: Dr. Anthony F. Kirkpatrick, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd., MDC 59, Tampa FL 33612-4799; rsmith@com1.Med.USF.Edu

© 1997 Canadian Medical Association (text and abstract/résumé)

See also:
  • Article: In the shadow of plenty, Cuba copes with a crippled health care system, R.C. Williams [full text]
Abstract

In March 1997 the American Association of World Health (AAWH) published a report on the impact of the US trade embargo against Cuba on health care in Cuba. In this issue Dr. Robin Williams shares her observations as part of a delegation of medical experts who visited Cuba to verify the AAWH's findings (page 291 [full text]). She describes a once impressive health care system beleaguered by drug shortages and equipment failures and a nation's health undermined by a lack of adequate food supplies and clean water. In May 1997 the US State Department issued a brief report rebutting the findings of the AAWH. In this editorial the author examines the State Department's report and concludes that many of the assertions it makes are misleading or false. He argues that this misinformation amounts to a cover-up of the direct, devastating effects of the US embargo on the health status of the Cuban people.

Résumé

En mars 1997, l'American Association of World Health (AAWH) a publié un rapport au sujet de l'impact qu'a eu, sur les soins de santé à Cuba, l'embargo commercial imposé par les États-Unis. Dans ce numéro, le Dr Robin Williams fait part de ses observations comme membre d'une délégation d'experts médicaux qui ont visité Cuba pour vérifier les constatations de l'AAWH (page 291 [full text]). Elle décrit un système de soins de santé auparavant impressionnant qui est assiégé par les pénuries de médicaments et les pannes d'équipement, ainsi que l'état de santé de la population qui est miné par le manque d'aliments et d'eau propre en quantité suffisante. En mai 1997, le Département d'État des États-Unis a publié un bref rapport pour réfuter les constatations de l'AAWH. Dans cet éditorial, l'auteur analyse le rapport du Département d'État et conclut qu'un grand nombre des affirmations qu'il contient sont trompeuses ou fausses. Il soutient que ces renseignements erronés équivalent à une dissimulation des effets directs et dévastateurs que l'embargo américain a eus sur l'état de santé de la population cubaine.

For more than 30 years the US government has maintained a crippling trade embargo against Cuba. Although the terms of the embargo have altered with successive administrations, the most important recent developments are the Cuban Democracy Act (CDA) of 1992 and the Helms­Burton Act of 1996. By prohibiting foreign subsidiaries of US companies from trading with Cuba, the CDA reimposes controls that were relaxed in the 1970s. Direct flights between the 2 countries are banned, and aircraft carrying emergency medical supplies for Cuba are prohibited from landing in the US. In addition, foreign vessels are prevented from loading and unloading freight in US harbours for 6 months after having stopped in Cuba. The Helms­Burton Act threatens with prosecution in US courts any foreign investor who has interests involving property in Cuba that was confiscated from a US citizen by the Castro government.1,2

In direct violation of international law, the embargo explicitly prohibits the sale of food to Cuba by US companies and their foreign subsidiaries. Medicines and medical supplies are nominally excluded from the embargo, but the almost insuperable bureaucratic restrictions imposed by the CDA on such shipments lead to inordinate delays, cost increases and limited access to some of the most important medical products. These obstacles amount to a de facto embargo on medical supplies.1,2

In 1992 Cuba was in a severe economic depression, largely resulting from a loss of preferential trade with the Soviet bloc. Cuba turned to US foreign subsidiaries, from whom it received $500­600 million per year in imports -- 90% of which was food and medicine. The American Public Health Association warned the US government that tightening the embargo would lead to the abrupt cessation of this supply of essential goods and result in widespread famine.1 Indeed, 5 months after passage of the CDA, food shortages in Cuba set the scene for the worst epidemic of neurologic disease this century. More than 50 000 people suffered from optic neuropathy, deafness, loss of sensation and pain in the extremities, and a spinal cord disorder that impaired walking and bladder control.1

The tightening of the embargo by the CDA has precipitated the deterioration of what the American Association for World Health (AAWH) describes as a "model primary health care system."2 In this issue Dr. Robin Williams describes the impact of drug and food shortages, equipment failures, and a lack of clean water supplies on health and health care in Cuba (page 291 [full text]). The embargo has lead to a marked decline in surgical services, delays in diagnosis and treatment, a decline in quality of hospital care, and increased rates of water-borne disease, malnutrition, unnecessary suffering and premature death. A Cuban official has described the US stranglehold on food and medicines as amounting to "genocide."3

Truth and denial

In February 1995 the Inter-American Commission on Human Rights of the Organization of American States stated in a letter to the US government that the "virtually unattainable" terms of trade in food and medicine with Cuba contravened international law. The letter called on the US to take "effective and speedy" steps to remedy the situation.4 Washington made no changes. The US government remained relatively quiet on the matter until May of this year, when the AAWH published a 300-page report on the impact of the US embargo on health and nutrition in Cuba, in which it concluded that "the embargo is driving the [Cuban health care] system towards crisis and causing significant suffering and death."2 The State Department released a 6-page "fact sheet" rebutting the AAWH's findings.5

The purpose of the "fact sheet" is to reject the entire basis of the AAWH's findings. In so doing, it makes statements that are misleading or simply false. Cuba's shortage of medicines and medical supplies, it argues, is not the result of US policy but rather of the Cuban government's "continued adherence to a discredited communist economic model,"5 which requires a deliberate emphasis on military spending at the expense of other priorities such as health care. The fact sheet reports that "According to the Pan American Health Organization [PAHO], the Cuban Government currently devotes a smaller percentage of its budget for healthcare than such regional countries as Jamaica, Costa Rica and the Dominican Republic." In fact, the most recent PAHO figures show that Cuban government expenditures on health, as a share of gross domestic product, are higher than health expenditures in any of the other 48 countries and territories in the region (except Canada) and are 34% higher than those in the US (Pamela Henderson, Consultant, Public Policies and Health Program, PAHO, Washington: personal communication, 1997).

Two of the indicators most often used by the United Nations to assess a country's overall health status are the infant mortality rate and the under-5 mortality rate. Cuba ranks 27th in the world for both indicators, ahead of all other Latin American countries. The US ranks only 1 notch above Cuba, at 26th for both indicators.6 Working with a per capita gross domestic product lower than any of the other Latin American countries named by the State Department and less than one-twentieth of the US,6 Cuba has managed to provide free, universal and comprehensive health care coverage to its citizens, building a health care system that is "uniformly considered the preeminent model in the Third World".2

Recently, the American Public Health Association reported that "Even in the worst economic times, Cuba has consistently made health a top priority and has allocated the funds necessary to maintain the health system. While other countries throughout the world responded to global recession by cutting back on resources dedicated to health, Cuba has sustained its investment in health."7 Castro's concern for public health has been recognized by the World Health Organization (WHO).

The US embargo has a direct impact on the life expectancy of people in Cuba. As Jose Teruel, a physician who monitors Cuba for PAHO, has remarked, "You're probably talking about a shortening of lives through the embargo, denying people medicines and care who would have better care in a normal situation."8 Indeed, a recent report has noted an increase in the number of deaths in the elderly Cuban population.9 Preferential distribution of scarce goods and priority programs for children and women will continue to increase the vulnerability of elderly people.

US companies and foreign US subsidiaries

The US State Department maintains that "The US embargo does NOT deny medicines and medical supplies to the Cuban people."5 The truth is that the terms of the embargo create serious obstacles for US companies and their foreign subsidiaries who might wish to sell medical products to Cuba. These obstacles include strict requirements for export licences. To obtain an export licence the supplier must satisfy US government officials that the product will not be used in human rights abuses, for military purposes, in the treatment of non-Cuban nationals or in the biotechnology industry. The export of raw materials and equipment for pharmaceuticals manufacturing is prohibited altogether. Blanket licences to cover ongoing export to Cuba of a particular product cannot be obtained; a separate licence must be obtained for each shipment, and each licence application can take 3 to 12 months to be approved.1,2

Exporters are responsible for "on-site inspections" to ensure that medical supplies are not diverted from their intended use; this entails considerable cost to the supplier and, if certain procedures are not followed, carries the risk of huge financial penalties and possible imprisonment.1 Carried to its logical extreme, the on-site inspection requirement means that shipments can be followed into physicians' offices, hospitals and clinics throughout Cuba to observe their actual use. The Cuban government has allowed some of these on-site inspections, even though they intrude on Cuba's sovereignty.1 Since enactment of the CDA, no direct sales of medical products have been made by US parent companies to Cuba, and only 4 foreign subsidiaries have braved the regulations and managed to sell medical products to Cuba; this number represents less than 4% of pre-CDA levels.1,2 Even the WHO has been hamstrung in its ability to facilitate the sale of medical supplies.1 Even if a medical supplier were able to obtain a license and arrange for on-site inspections it would be confronted with delays and increased costs created by restrictions on sea and air traffic between Cuba and the US. Shipping costs have increased as much as 4-fold because of US regulations.

From the Cuban perspective, the embargo acts as a deterrent to exploring long-term purchases from the US market, for fear that critical pharmaceuticals and equipment would be held hostage, either to the decisions of the US Commerce and Treasury Departments or to the inclination of a given US administration or Congress.

The aggressive enforcement of the terms of the embargo serves as a further disincentive to trade. For example, in October 1995 the US Treasury Department announced that it would impose fines of up to US$1 million for corporations and prison terms of up to 10 years for individuals for "technical and inadvertent" violations of the embargo.1 In the same announcement the Treasury Department disclosed that it has prosecuted Merck, the largest pharmaceutical company in the US, for an exchange of scientific information with Cuba. Merck described the exchange of information as an opportunity to assist WHO in its Pan-American health care activities.1 Similarly, in Miami the US government promoted a hotline to engage the public in reporting suspected illegal shipments of medications to Cuba. This adverse publicity intimidates other medical companies that might wish to sell their products to Cuba.

Non-US companies

The State Department claims that "The US embargo on Cuba affects only US companies and their subsidiaries. Other nations and companies are free to trade with Cuba."5 This is untrue. First, the restrictions on sea and air traffic noted earlier significantly hinder the movement of medical supplies even from non-US companies. Second, if a product from a non-US company contains more than 10% of a US component, it is subject to the same embargo restrictions as US products. Third, the Helms­Burton Act and the potential loss of US aid serve as strong disincentives to foreign investors.

Non-US companies have a limited range of critical pharmaceutical products to sell, since roughly 50% of the most important drugs on the world market are controlled by US manufacturers or their subsidiaries.1,2 The tightening of the embargo, together with recent acquisitions of foreign drug manufacturers by US companies10 has severely limited access to essential medical supplies in Cuba; these include cardiac pacemakers, numerous drugs and diagnostic agents.1,2 There are numerous well-documented cases in which Cuba has been forced to seek new suppliers of critical medical products on short notice because a US company merged with or acquired a foreign medical company.1,2

Humanitarian aid?

In its fact sheet, the US State Department claims that "The Cuban Democracy Act encourages the donations of humanitarian supplies to the people of Cuba. . . . The US government has licensed more than $150 million in humanitarian assistance to Cuba over the last four years."5 This figure is hardly persuasive as a demonstration of compassion toward the Cuban people. The amount of US$150 million annually since 1992 works out to $37 million per year, as compared with the US$500­600 million a year in trade -- most of it in food and medicine -- with US foreign subsidiaries before the enactment of the CDA. Moreover, licencing and other bureaucratic requirements present obstacles similar to those presented by commercial trade. US government officials scrutinize the parties and commodities involved, and donations can be made only to nongovernment organizations, stipulations that severely limit the number of potential players.2

Even if a donor obtains a licence to ship medicines to Cuba and finds a recipient acceptable to the US, serious obstacles remain. For example, one of the largest donors of medicines to Cuba, the Catholic Relief Services, notes that it takes 1­2 months to receive a licence for each shipment. But the biggest problem is the need to ship through third countries such as Canada and Mexico, causing long delays and an "almost prohibitive" increase in freight costs (Chris Gilson, Director, Cuba Program, Catholic Relief Services, Baltimore: personal communication, 1997). Individual gift parcels are limited to $200 per month per individual. This amount cannot meet the needs, even for medicines alone, of people suffering from conditions such as AIDS or cancer. Accusations that donations are exported from Cuba or sold to ailing tourists is not consistent with the opinion of the US Department of Commerce, whose 1994­95 report on donations to Cuba states that such diversion is "insignificant."11

Humanitarian donations cannot sustain a health care system. They cannot meet the demands posed by emergency shortages, long-term care, the need for a full range of therapeutic options, expiration of donated medicines, or the upkeep and repair of equipment. Cuba must be able to independently purchase medicines and equipment to maintain an adequate level of health care for its people.

Conclusion

The American public deserve the facts from their government, not blatant propaganda based on cooked statistics. Honest government and informed decision-making require the truthful presentation of relevant data. To do less not only further isolates the US in its Cuban policy, but also undermines the very foundations of democracy. The US State Department is promulgating information about the US embargo that is demonstrably false. But there is more at stake here than the truth. By blocking access to the basic necessities of life in the midst of a severe economic depression, the US government is contributing directly to a significant increase in suffering and premature death within a civilian population just 90 miles south of its border.

References

  1. Kirkpatrick AF. Role of the USA in shortage of food and medicine in Cuba. Lancet 1996;348:1489-91.
  2. American Association of World Health. Denial of food and medicine: the impact of the US embargo on health and nutrition in Cuba [executive summary]. Washington: The Association; 1997.
  3. In brief [news item]. CubaINFO [Washington] 1997;9(7):7.
  4. Mejfa AT, for the Inter-American Commission on Human Rights, Organization of American States. Letter to the United States of America. Washington: The Commission; 17 Feb 1995.
  5. Office of the Spokesperson, US Department of State. The US embargo and healthcare in Cuba: myth versus reality [fact sheet]. Washington: The Department, 14 May 1997.
  6. UNICEF. The state of the world's children 1996. New York: United Nations, 1996.
  7. American Public Health Association. The politics of suffering: the impact of the US embargo on the helath of the Cuban people. Washington: The Association; 1993.
  8. Collie T. Doctor attacks Cuba embargo. Tampa Tribune [Tampa, Fla] 1996; Nov 29:6 [Florida Metro section].
  9. Garfield R, Santana S. The impact of the economic crisis and the US embargo on health in Cuba. Am J Public Health 1997;87:15-20.
  10. Weber J. Robust and ready to brawl: drugmakers are flush, so more mergers -- even hostile ones -- may be on the horizon. Bus Week 1996;
    Jan 8:96.
  11. US Department of Commerce. Export administration annual report 1994­1995: report on foreign policy controls. Washington: The Department; 1995:III-19.

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| CMAJ August 1, 1997 (vol 157, no 3) / JAMC le 1er août 1997 (vol 157, no 3) |