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Effect of the U.S.Embargo and Economic Decline on Health in Cuba
Miche`le Barry,MD
This article describes the ways in which economic crisis and the bargo have affected Cuba’s health care system during the past15years.With the demi of subsidized trade,the abnce of aid from the former Soviet Union, and the progressive tightening of U.S.sanctions,Cuba’s model health care system has become threatened by ri-ous shortages of medical supplies.Several public health catastrophes have occurred,including an epidemic of blindness that was partially attributed to a dramatic de-crea in access to nutrients;an outbreak of the Guillain–Barre´syndrome caud by lack of chlorination chemicals; and an epidemic of lye ingestion in toddlers due to vere shortages of soap.The policy of mandatory quarantine for HIV-infected Cubans has evolved into a less rigid system. Although the prevalence of HIV infection in Cuba is low compared with that in the United States and other Carib-bean nations,it is threatened by prostitution,which has incread along with tourism.In general,economic sanc-tions may have an unintended but profound effect on the health and nutrition of vulnerable populations.
Ann Intern Med.2000;132:151-154.
For the author affiliation and current address,e end of text.
I n early1999,I had the opportunity to travel to Havana,Cuba,as a member of a working group for the Social Science Rearch Council(SSRC). The purpo of the visit was to review proposals for funding of collaborative projects in the social and natural sciences that would involve exchange be-tween the United States and Cuba.My last trip to Cuba had been15years before,as a guest lecturer at the Instituto Pedro Kouri.During my current visit,I was struck by the profound changes that have occurred in a health care system that was once considered the preeminent model for developing countries(1).
This article describes the effects of economic cri-sis and the bargo on the health of Cuba’s11 million citizens.It includes personal reflections on the ways in which the health care system has dete-riorated during years of progressive U.S.sanctions. Clearly,the situation in Cuba is complex and eco-nomic decisions made by the Cuban government may also have weakened the public health infra-structure.Embargoes affect health indirectly.How-ever,a health care system such as Cuba’s,which allows universal access to care,provides a unique opportunity to examine health trends that may have been influenced by bargoes on sales of pharmaceutical products and food.
The bargo against Cuba began in1961. Although the embargo has always had a negative effect on the Cuban economy,its effect on the health care system had been significantly offt by subsidized trade and aid from the former Soviet Union,countries in the socialist bloc,and western Europe.Public health and universal access to free medical care have been priorities of Fidel Castro’s government since its inception in1959(1–3).Polio, malaria,tetanus,diphtheria,and human rabies have been eradicated from the island(1,3).General practitioners and nurs deliver preventive care through the Family Doctor Program;one physician and one nur are personally responsible for each neighborhood of100to200Cuban families(4). Cuba has twice as many physicians per capita as the United States,and the infant mortality rate is10 per1000births(Table)(3,5).In the late1980s and early1990s,health care statistics in Cuba were far better than in other Latin American countries,and Cuban physicians were in demand in underrved foreign countries becau of their experti in public health promotion(3,4).
However,the socialist bloc crumbled in the late 1980s,and the bargo suddenly became much more of a threat to the Cuban health care system.Cuba lost$4to$6billion annually in sub-sidized trade,and almost overnight,imports re-quired hard currency(3).Cuba no longer had ac-cess through the eastern bloc to the raw materials needed to manufacture pharmaceutical products, and lack of c
urrency made it difficult to purcha drugs and medical equipment in western Europe. The Cuban Democracy Act of1992verely aggra-vated the situation by prohibiting foreign subsidiar-ies of panies from trading with Cuba.This act reflects one of the few sanctions worldwide that
See related article on pp158-161
and editorial comment on pp155-157.
©2000American College of Physicians–American Society of Internal Medicine151
explicitly includes food and further defines trading restrictions that block access to medical supplies(2). As U.S.pharmaceutical and biotechnologyfirms merged with European companies,Cuban physi-cians had to cope with a progressive lack of criti-cally needed medicines,diagnostic tools,vaccines, and medical machinery that had previously been available or affordable(3,7).Since1975,approxi-mately50%of all newly patented drugs distributed worldwide have been produced by U.S.drug com-panies.The drugs are unavailable in Cuba unless they are sold by an intermediary,often at prohibi-tive cost(7).The1996Helms–Burton law further discouraged foreign investors in the health care in-dustry from contemplating even limited trade with Cuba by threatening non-U.S.intermediaries with lawsuits in urts(3).
During my recent visit,the human conquences of the decisions were all too evident in Cuban streets and on the wards of Cuban hospitals.Food was obviously scarce in bodegas,or grocery stores, as was the technologically advanced machinery that the Cubans had been so proud to display15years before.The median weight of children and adults has decread dramatically becau the amount of food supplied at workplaces and schools has been substantially reduced(3).
Several public health catastrophes on the island have been directly attributed to the bargo (8–10).In1992and1993,more than50000cas of optic and peripheral neuropathy occurred.This ep-idemic was attributed to reduced nutrient intake, which was caud by food shortages,and local to-bacco u,which incread the risk for blindness. U of costly multivitamin supplements dramatically decread the incidence of blindness(9,10).In addition,an epidemic of esophageal stenosis in tod-dlers who inadvertently drank liquid lye is believed to be the result of a soap shortage that caud Cubans to u lye as a substitute(8).A1994outbreak of the Guillain–Barre´syndrome in Havana was caud by water that had been contaminated with Campy-lobacter species becau chlorination chemicals were not available for purification(8).Serious shortages of insulin,other medications,and vaccines have also taken their toll,especially on the health of children (2,3).
I reviewed veral HIV projects for the SSRC this year and was struck by the difference in Cuba’s ap
proach to AIDS since my last visit.In1983,I gave a lecture about HIV and was bluntly told that becau homoxuality and intravenous drug usage did not exist in Cuba,AIDS would never become an meaningful issue.In1985,when thefirst cas of AIDS occurred among international workers return-ing from Angola,Cuba allotted$3million for HIV testing equipment(4).In1986,the Cuban Ministry of Health instituted HIV screening for large g-ments of the population,including all persons who had traveled abroad since1976and members of high-risk groups,such as prison inmates,workers in the tourist industry,sailors,pregnant women,and persons admitted to hospitals(4,11).Cuba re-stricted importation of blood products;incorporated HIV testing into routine health care screening;and, for the public safety of the collective community, quarantined persons with confirmed positive results on HIV tests in a Havana sanitarium(11).
This policy of quarantine drew charges of human rights violations,and,in respon,the Cuban AIDS program evolved.Thirteen additional sanitariums were constructed in each province of Cuba.This allowed HIV-positive residents to move clor to their communities and laid the groundwork for am-bulatory HIV care,which began in1993(4).Edu-cational programs and promotion of condom u were slowly combined with the identification of in-fected persons.Currently,most persons who are newly diagnod with HIV infection are asked to enter a sanitarium for6months to a year to par-ticipate in a
n intensive cour that covers mental and physical hygiene and safe-x practices.Sanitar-ium residents receive expensive medications,such as zidovudine and didanosine,free of charge(4);are paid their full wages or receive public assistance without working;and have above-average housing accommodations.They receive a high-calorie diet supplemented with animal protein,which is rationed
Table.Comparative Health Indicators*
Country1996Infant Mortality
Rate per1000Births 1996Life Expectancy1999AIDS Cas per
100000Persons
Mortality Rate in Children
Younger Than5Years of
Age per1000Births
n y n
官渡之战United States8762478 Cuba1076 6.910 Haiti9454122134 Dominican Republic45715456 Latin America and the Caribbean
(regional summary)3569NA43 *Modified from references5and6.NAϭnot available.
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哈密瓜奶昔
in the general population.Ambulatory patients must support themlvesfinancially but are eligible for special protein rations and free medications. Cuban officials believe that mandatory tracing and testing of xual partners of HIV-positive per-sons have resulted in the lowest reported prevalence of HIV in the hemisphere.As of May1999,Cuba reported a total of761cas of AIDS(6);the Table contrasts the AIDS rate in Cuba with tho in nearby countries(6).The quarantine policy may illustrate the tradeoffs that have characterized Cu-ban society,in which individual rights and freedoms may be abrogated for the public good.The current embargo has affected the availability of antiretrovi-ral therapy and reagents for HIV testing and CD4 cell counts(3).
From a more personal perspective,I was im-presd by the incread tourism in Cuba and the openness with which citizens discusd the failures of the revolution as well as its success.Large-scale prostitution was controlled after Castro came to power but has recently incread becau of t
he economic trade crisis and burgeoning tourism.Be-cau prostitutes threaten HIV containment,Castro has“cracked down”on jineterismo,or the x trade with tourists.
The Clinton Administration announced a recent initiative to expand relations with Cuba.This initia-tive was issued20March1998as a press relea and culminated in a baball game and permission to nd a limited amount of to relatives in Cuba.Most people e this initiative,which also permits more airplaneflights from the United States to Cuba,as a meaningless gesture that does not offer much economic relief to the general pop-ulation(12).Nevertheless,the Clinton Administra-tion has expedited cultural and academic exchanges. The SSRC has initiated requests for proposals for academic collaboration between scholars in Cuba and North America(www.acls/pro-cuba.htm), and dical student rotations and residency rotations will be permitted in rural Cuba under the sponsorship of a nonprofit U.Sanization,Med-ical Education Cooperation with Cuba(MEDICC) (dicc/body_index.html).
In the20th century,economic sanctions have be-come a common tool of foreign policy.Examples include the collective international sanctions against southern Rhodesia,Iraq,Serbia,Montenegro, Libya,Haiti,South Africa,Rwanda,Angola,and Somalia and unilateral U.S.sanctions against Nica-ragua,Cuba,Iran,Panama,and Sudan.Becau economic sanctions result in shortages of food and m
长耳朵的狗edical supplies,their most vere conquences are often felt by the persons who are least culpable and most vulnerable;untoward health quelae usu-ally occur in civilian rather than military populations (8).It has been shown that women and children younger than5years of age are particularly affected by food shortages and weakened public health in-frastructures caud by embargoes(13).
The bargo against Cuba,one of the few that includes both food and medicine,has been described as a war against public health with high human costs(10).Although the Cuban govern-ment’s curtailment of individual liberties and pri-vacy may be en as an abridgment of personal freedom,we as health care professionals have a moral duty to protest an embargo that engenders human suffering to achieve political objectives. Medicine,food,and water purification materials should be made available or,preferably,should be exempt from sanctions.Official monitoring of the effects of economic sanctions on civilian populations should become a high priority.
Addendum:In August1999,the U.S.Senate voted70to28in favor of eliminating unilateral export bans in an amendment to next year’s agri-cultural appropriations bill.This would have effec-tively ended the embargo on exporting food to Cuba.The U.S.Hou of Reprentatives sub-quently deleted this amendment in a Hou–Senate clod committee ssion.The U.S.Senate leaders are planning
yet another vote on legislation(Dodd/ Serrano legislation S.926/H.R.1644)that would permit the sale of food and medicine to Cuba.The date for this vote had not yet been decided when this article went to press.
From Yale University School of Medicine,New Haven,Connect-icut.
Acknowledgment:The author thanks Ms.Carolyn Karbowski for careful assistance and Drs.Elio Pe´rez-Stable and Mark Cullen and William Reisman,JD,for editorial comments.
Grant Support:The author’s trip to Cuba wasfinanced by Social Science Rearch Council.
Requests for Reprints:Miche`le Barry,MD,International Health Office,Yale University School of Medicine,333Cedar Street, New Haven,CT06520-8025.For reprint orders in quantities exceeding100,plea contact Barbara Hudson,Reprints Coor-dinator;phone,215-351-2657;e-mail,bhudson@mail.acponline.
References
1.Ubell RN.High-tech medicine in the Caribbean.25years of Cuban health
care.N Engl J Med.1983;309:1468-72.
2.Kuntz D.The politics of suffering:the impact of the bargo on the
health of the Cuban people.Report of a fact-finding trip to Cuba,June6-11, 1993.Int J Health Serv.1994;24:161-79.
3.Denial of food and medicine.The impact of the bargo on health
蛋挞配方
nutrition and in Cuba.Washington,DC:American Association of World Health;1997.
绚丽多彩造句4.Hanson H,Groce N.From quarantine to condoms:a report from recentfield
work on HIV control in Cuba.Med Anthropol.[In press].
5.UNICEF.State of the World’s Children.New York:Oxford Univ Pr;1998:94-7.
6.AIDS Surveillance in the Americas.Regional program on AIDS and STD.Pan
American World Health Organization,WHO/AHO/UNAIDS,Working Group on Global HIV/AIDS and STD Surveillance.Biannual report.Washington,DC:Pan American Health Organization/Regional Office of World Health Organization;
June1999.
7.Kirkpatrick AF.Role of the USA in shortage of food and medicine in Cuba.
18January2000•Annals of Internal Medicine•Volume132•Number2153
扬州好玩的地方Lancet.1996;348:1489-91.
8.Garfield R,Santana S.The impact of the economic crisis and the U.S.
embargo on health in Cuba.Am J Public Health.1997;87:15-20.
9.Epidemic optic neuropathy in Cuba—clinical characterization and risk factors.
The Cuba Neuropathy Field Investigation Team.N Engl J Med.1995;333: 1176-82.
教师形象10.Einberg,L.The sleep of reason produces monsters—human costs of eco-
nomic sanctions[Editorial].N Engl J Med.1997;336:1248-50.
11.Bayer R,Healton C.Controlling AIDS in Cuba.The logic of quarantine.
N Engl J Med.1989;320:1022-4.
12.Office of the Press Secretary.Washington,DC.Statement by the President,20
March1998.
13.Garfield R.The impact of economic embargoes on the health of women and
children.J Am Med Womens Assoc.1997;52:181-4.
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