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[GSN] Part 1: Economic Sanctions - Annals of Internal Medicine

------- Forwarded message follows -------
Date sent:              Fri, 18 Aug 2000 02:24:05 +1000
To:                     (Recipient list suppressed)
From:                   Lynette Dumble <>
Subject:                [GSN] Part 1: Economic Sanctions - Annals of Internal Medicine
        exposed as agent of State Dept!

Dear all,
Many will recall the January, 2000 issue of Annals of Internal Medicine,
where Michèle Barry from Yale University highlighted the
severe consequences of economic sanctions which were "often felt by the
persons who are least culpable and most vulnerable; untoward health sequelae
usually occur in civilian rather than military populations; and ... that
women and children younger than 5 years of age are particularly affected by
food shortages and weakened public health infrastructures caused by

In the face of Michèle Barry's first hand evidence [full article repeated
below], the Annals of Internal Medicine saw fit to give Madeleine Albright
the space to defend the State Department's position on economic sanctions
[article available on request or at
""]. In this
week's Annals of Internal Medicine, 9 letters [8 from physicians, one from a
registered nurse - to follow in part II Economic Santions] illustrate that
the journal surrendered its supposedly neutral pages to the State back in
January 2000, when Madeleine Albright's defence of the State Department's
sanction policy was, at best, UNTRUTHFUL, and, at worst, A PACK OF LIES.

An honorable Annals' editor and an honorable Secretary of State would
resign, but is either honorable? - Lynette.
Annals of Internal Medicine, 18 January 2000, 132:151-154.
Effect of the U.S. Embargo and Economic Decline on Health in Cuba
Michèle Barry, MD

This article describes the ways in which economic crisis and the U.S.
embargo have affected Cuba's health care system during the past 15 years.
With the demise of subsidized trade, the absence 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 serious shortages of medical
supplies. Several public health catastrophes have occurred, including an

epidemic of blindness that was partially attributed to a dramatic decrease
in access to nutrients; an outbreak of the Guillain-Barré syndrome caused by
lack of chlorination chemicals; and an epidemic of lye ingestion in toddlers
due to severe 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 Caribbean nations, it is threatened by prostitution, which
has increased along with tourism. In general, economic sanctions may have an
unintended but profound effect on the health and nutrition of vulnerable
Ann Intern Med. 2000;132:151-154. Annals of Internal Medicine is published
twice monthly and copyrighted © 2000 by the American College of
Physicians-American Society of Internal Medicine.

For the author affiliation and current address, see end of text.
In early 1999, I had the opportunity to travel to Havana, Cuba, as a member
of a working group for the Social Science Research Council (SSRC). The
purpose of the visit was to review proposals for funding of collaborative

projects in the social and natural sciences that would involve exchange
between the United States and Cuba. My last trip to Cuba had been 15 years

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 crisis and the U.S. embargo
on the health of Cuba's 11 million citizens. It includes personal
reflections on the ways in which the health care system has deteriorated
during years of progressive U.S. sanctions. Clearly, the situation in Cuba
is complex and economic decisions made by the Cuban government may also have
weakened the public health infrastructure. Embargoes affect health
indirectly. However, 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 U.S. embargoes on sales of
pharmaceutical products and food.
The U.S. embargo against Cuba began in 1961. Although the embargo has always
had a negative effect on the Cuban economy, its effect on the health care
system had been significantly offset 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 in 1959 (1-3). Polio,
malaria, tetanus, diphtheria, and human rabies have been eradicated from the
island (1, 3). General practitioners and nurses deliver preventive care
through the Family Doctor Program; one physician and one nurse are
personally responsible for each neighborhood of 100 to 200 Cuban families
(4). Cuba has twice as many physicians per capita as the United States, and
the infant mortality rate is 10 per 1000 births (Table) (3, 5). In the late
1980s and early 1990s, health care statistics in Cuba were far better than
in other Latin American countries, and Cuban physicians were in demand in
underserved foreign countries because of their expertise in public health
promotion (3, 4).
However, the socialist bloc crumbled in the late 1980s, and the U.S. embargo
suddenly became much more of a threat to the Cuban health care system. Cuba
lost $4 to $6 billion annually in subsidized trade, and almost overnight,
imports required hard currency (3). Cuba no longer had access through the
eastern bloc to the raw materials needed to manufacture pharmaceutical
products, and lack of currency made it difficult to purchase drugs and
medical equipment in western Europe. The Cuban Democracy Act of 1992
severely aggravated the situation by prohibiting foreign subsidiaries of
U.S. companies from trading with Cuba. This act reflects one of the few
sanctions worldwide that explicitly includes food and further defines
trading restrictions that block access to medical supplies (2).

As U.S. pharmaceutical and biotechnology firms merged with European
companies, Cuban physicians had to cope with a progressive lack of

critically needed medicines, diagnostic tools, vaccines, and medical
machinery that had previously been available or affordable (3, 7). Since

1975, approximately 50% of all newly patented drugs distributed worldwide
have been produced by U.S. drug companies. These drugs are unavailable in
Cuba unless they are sold by an intermediary, often at prohibitive cost (7).
The 1996 Helms-Burton law further discouraged foreign investors in the
health care industry from contemplating even limited trade with Cuba by
threatening non-U.S. intermediaries with lawsuits in U.S. courts (3).
During my recent visit, the human consequences of these 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 display 15 years
before. The median weight of children and adults has decreased dramatically
because 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 U.S. embargo (8-10). In 1992 and 1993, more than 50 000
cases of optic and peripheral neuropathy occurred. This epidemic was
attributed to reduced nutrient intake, which was caused by food shortages,
and local tobacco use, which increased the risk for blindness. Use of costly

multivitamin supplements dramatically decreased the incidence of blindness
(9, 10). In addition, an epidemic of esophageal stenosis in toddlers who
inadvertently drank liquid lye is believed to be the result of a soap
shortage that caused Cubans to use lye as a substitute (8). A 1994 outbreak
of the Guillain-Barré syndrome in Havana was caused by water that had been
contaminated with Campylobacter species because 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 several HIV projects for the SSRC this year and was struck by the
difference in Cuba's approach to AIDS since my last visit. In 1983, I gave a
lecture about HIV and was bluntly told that because homosexuality and
intravenous drug usage did not exist in Cuba, AIDS would never become an
meaningful issue. In 1985, when the first cases of AIDS occurred among
international workers returning from Angola, Cuba allotted $3 million for
HIV testing equipment (4). In 1986, the Cuban Ministry of Health instituted
HIV screening for large segments of the population, including all persons
who had traveled abroad since 1976 and 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 restricted 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

response, the Cuban AIDS program evolved. Thirteen additional sanitariums
were constructed in each province of Cuba. This allowed HIV-positive

residents to move closer to their communities and laid the groundwork for
ambulatory HIV care, which began in 1993 (4). Educational programs and
promotion of condom use were slowly combined with the identification of
infected persons. Currently, most persons who are newly diagnosed with HIV
infection are asked to enter a sanitarium for 6 months to a year to
participate in an intensive course that covers mental and physical hygiene
and safe-sex practices. Sanitarium 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 in the general population. Ambulatory
patients must support themselves financially but are eligible for special
protein rations and free medications.

Cuban officials believe that mandatory tracing and testing of sexual
partners of HIV-positive persons have resulted in the lowest reported
prevalence of HIV in the hemisphere. As of May 1999, Cuba reported a total
of 761 cases of AIDS (6); the Table contrasts the AIDS rate in Cuba with
those in nearby countries (6). The quarantine policy may illustrate the

tradeoffs that have characterized Cuban society, in which individual rights
and freedoms may be abrogated for the public good. The current embargo has
affected the availability of antiretroviral therapy and reagents for HIV
testing and CD4 cell counts (3).
>From a more personal perspective, I was impressed by the increased tourism
in Cuba and the openness with which citizens discussed the failures of the
revolution as well as its successes. Large-scale prostitution was controlled
after Castro came to power but has recently increased because of the
economic trade crisis and burgeoning tourism. Because prostitutes threaten
HIV containment, Castro has "cracked down" on jineterismo, or the sex trade
with tourists.
The Clinton Administration announced a recent initiative to expand relations
with Cuba. This initiative was issued 20 March 1998 as a press release and
culminated in a baseball game and permission to send a limited amount of
U.S. money to relatives in Cuba. Most people see this initiative, which also
permits more airplane flights from the United States to Cuba, as a
meaningless gesture that does not offer much economic relief to the general
population (12). Nevertheless, the Clinton Administration has expedited
cultural and academic exchanges. The SSRC has initiated requests for
proposals for academic collaboration between scholars in Cuba and North
America (, and U.S. medical student
rotations and residency rotations will be permitted in rural Cuba under the
sponsorship of a nonprofit U.S. organization, Medical Education Cooperation
with Cuba (MEDICC) (

In the 20th century, economic sanctions have become 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 Nicaragua,
Cuba, Iran, Panama, and Sudan. Because economic sanctions result in
shortages of food and medical supplies, their most severe consequences are
often felt by the persons who are least culpable and most vulnerable;
untoward health sequelae usually occur in civilian rather than military
populations (8). It has been shown that women and children younger than 5
years of age are particularly affected by food shortages and weakened public
health infrastructures caused by embargoes (13).
The U.S. embargo 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 government's curtailment of individual
liberties and privacy may be seen 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 August 1999, the U.S. Senate voted 70 to 28 in favor of
eliminating unilateral export bans in an amendment to next year's
agricultural appropriations bill. This would have effectively ended the
embargo on exporting food to Cuba. The U.S. House of Representatives
subsequently deleted this amendment in a House-Senate closed committee
session. 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, Connecticut.
Acknowledgment: The author thanks Ms. Carolyn Karbowski for careful
assistance and Drs. Eliseo Pérez-Stable and Mark Cullen and William Reisman,
JD, for editorial comments.
Grant Support: The author's trip to Cuba was financed by Social Science
Research Council.
Requests for Reprints: Michèle Barry, MD, International Health Office, Yale
University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8025.
For reprint orders in quantities exceeding 100, please contact Barbara
Hudson, Reprints Coordinator; phone, 215-351-2657; e-mail,
1. Ubell RN. High-tech medicine in the Caribbean. 25 years of Cuban health
care. N Engl J Med. 1983;309:1468-72.
2. Kuntz D. The politics of suffering: the impact of the U.S. embargo on the
health of the Cuban people. Report of a fact-finding trip to Cuba, June
6-11, 1993. Int J Health Serv. 1994;24:161-79.
3. Denial of food and medicine. The impact of the U.S. embargo on health
nutrition and in Cuba. Washington, DC: American Association of World Health;

4. Hanson H, Groce N. From quarantine to condoms: a report from recent field
work on HIV control in Cuba. Med Anthropol. [In press].
5. UNICEF. State of the World's Children. New York: Oxford Univ Pr;

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; June 1999.
7. Kirkpatrick AF. Role of the USA in shortage of food and medicine in Cuba.
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.
10. Eisenberg, L. The sleep of reason produces monsters-human costs of
economic 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 March 1998.
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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