Role of the USA in shortage of food and medicine in Cuba For over 30 years an embargo by the USA has restricted Cuba’s ability to purchase foods and medicines. In 1992, theUSA enacted the Cuban Democracy Act (CDA), which “exempted” the sale of medicines from the embargo. However,the implementation of the CDA’s requirements and the intensification of the embargo as a result of the passage of theHelms-Burton Act in March, 1996, have undermined the purpose of the medicine exemption. The resultant lack of foodand medicine to Cuba contributed to the worst epidemic of neurological disease this century. The Inter-AmericanCommission on Human Rights of the Organization of American States has informed the US Government that suchactivities violate international law and has requested that the US take immediate steps to exempt food and medicinefrom the embargo.
Health professionals need to understand how an economic embargo of a country can have a direct,negative effect on its public health. The US embargo against Cuba is unprecedented because it imposes restrictions on the sale of medicine and food. Indeed, theClinton Administration described the Cuban embargo as “the most comprehensive embargo the United States has My aim was to determine to what extent recent US Government policies contribute to a shortage ofmedicines and medical equipment in Cuba, and how.
The data were gathered from telephone conversations, records, and written communications obtained between 1993 and 1996. It should be noted that some of the participants in this survey did not want their cooperation Figure: Development of 265 major global drugs from 1970 to to be construed as taking a position on any US “Major global drugs” must have been marketed or have reached thepost-clinical stage in at least 6 of 7 of the world’s leading markets: theUSA, Japan, Germany, France, Italy, the UK, and Spain. A presence in 6 or 7 markets requires the inclusion of at least two or three leadingcontinents, and acceptance by various medical cultures. “National The USA has immense control over the availability of origin” is the nationality of the originating company, or the parent to essential drugs worldwide. The figure shows that the US which the originator belonged at the time of market introduction. Dataadapted from ref 2.
pharmaceutical industry has a significant global lead inthe discovery and development of major drugs. The US increased administrative cost. If certain procedures were monopoly spans almost all therapeutic and diagnostic not followed, the manufacturers could be subject to penalties of up to $1 million per violation for corporations For over 30 years an embargo by the US has restricted and prison terms up to 10 years for individuals. The Cuba’s access to these essential medicines.4 However, Cuban Government has allowed some of these on-site with the tightening of the embargo in 1992 through the inspections, even though it intrudes on Cuba’s passage of the Cuban Democracy Act (CDA) many of these medicines became virtually unattainable. The new The US Government, for its part, seems to make a restrictions required that the President of the USA certify, concerted effort to frustrate medical companies through on-site inspections approved by the President, attempting to export goods to Cuba. For example, that all components of a shipment of medical products to Johnson & Johnson was forced to wait a year to receive an Cuba were used for the purpose intended.5 The US export licence.6 Other companies have found the licence- Government knew that it could not do these on-site application process insurmountable, even for the sale of inspections. The US Government therefore shifted the $200 of replacement parts for radiographic equipment burden of on-site inspections to the exporters. The (Cody N, Picker International, Cleveland, Ohio, USA; manufacturers had to accept the responsibility for personal communication). According to Iris Medical, an verifying the end use of each product sold to Cuba, at an international supplier of ophthalmological equipment,“Despite a substantial expenditure of time and resources, Iris Medical was unable to establish a meaningful dialog with the US Department of Commerce in a mannerconsistent with standard business practices” (Arias E, Iris University of South Florida College of Medicine,12901 Bruce B Downs Blvd, Box 59, Tampa, Florida 33612, USA Medical, Mountain View, California, USA; personal communication). Even WHO is subject to the CDA Commerce departmentVentilator parts (Sweden) Documents obtained through the Freedom of Information Act; request to the Office of Foreign Asset Control of the US Department of Treasury, Aug 27, 1996. Data also obtained bythe author from the licensee.
Table: US licence applications for sale of medical products to Cuba restrictions.6 Consequently, as the table shows, only a few “traffics” in American property that was confiscated by of the world’s medical companies have attempted to brave the Cuban government after the 1959 takeover by Fidel US regulations since the enactment of the CDA. The Castro.8 Another provision would allow US citizens to sue number of companies granted US licences to sell to Cuba such firms—ie, those trafficking in nationalised has fallen to less than 4% of pre-CDA levels.4 properties, in US courts. President Clinton has postponed The largest pharmaceutical firm in the USA, Merck, the implementation of the latter provision until Jan 15, announced on Dec 19, 1995, that it will never do 1997. But even if he renews the suspension of the lawsuit business with Cuba while the embargo is in place. Merck part of the Act, the law will remain on the books and was prosecuted by the US Government for an exchange serve as a disincentive to companies that may wish to sell of scientific information with Cuba. Merck described the medicines to Cuba. What makes the current law so exchange of information as an opportunity to assist WHO difficult to change is the way it came into effect in March.
in its Pan-American health-care activities. There was no In a major concession to the Republican-controlled commercial transaction. Merck reports that they believed Congress, Clinton relinquished some of his authority as that they had a “gentleman’s agreement” with the US President over foreign affairs and agreed that the only way Department of Treasury to keep a low profile about the the Act could be amended or overturned is by another act incident (Bearse S, Merck, Whitehouse, New Jersey, of Congress. It is unsurprising that Mexico, Canada, and USA; personal communication). However, when the European Union are threatening to retaliate if the President Fidel Castro came to New York City in October, 1995, to attend the United Nations’ 50th For Cuba, the costs of medical products have increased anniversary celebration, the US Treasury Department because the country has few potential suppliers, and therefore little negotiating strength. Cubans complain that International Murex Technologies of the USA acquired a non-US medical companies raise prices because of diagnostics company from the UK, Murex banned the increased transportation costs and increased risk due to sale of diagnostic products from the UK to Cuba for fear possible reprisals from the US Government. The effect on of reprisals by the US Government and the risk of adverse Cuba’s health system is increased costs, shipping delays, publicity (Ramsey S, International Murex Corporation, and restricted access to some of the most important Norcross, Georgia, USA; personal communication). As a medical products because they are subject to US result, Cuba had to find a new supplier of diagnostic products followed by 3–6 months of validation testing in In February, 1995, a group of concerned US citizens, Cuba before some of the products could be used.
including me, approached the Inter-American Merck’s and Murex’s experiences with the Cuban Commission on Human Rights of the Organization of embargo are only examples of other US-induced barriers American States (OAS) to point out that the inclusion of and deterrents for trade in medical products with Cuba.
foods and medicines in the US trade embargo against These include fear of huge financial penalties and Cuba was a violation of common international law. The imprisonment of company employees, increased legal matter was discussed at hearings at the OAS that month costs, US Government prosecution for minor and and the Commission—in a little-noticed letter—urged the inadvertent violations of the Cuban embargo, and follow- US Government to end restrictions on shipment of food up solicitation of the press for adverse publicity against and medicines to Cuba, calling them a violation of the medical company and its employees.
international law.9 This development was significantbecause the OAS has excluded Cuba from mem- bership of the organisation. In addition, the OAS was one The US embargo imposes significant restrictions on Cuba of the first international organisations to deplore acquiring non-US products. For example, foreign vessels violations of human rights by the Fidel Castro’s are banned from loading or unloading freight anywhere in the US for at least 6 months after having stopped in In response to the opinion of the OAS, the USA Cuba. Similarly, aircraft carrying emergency medical maintains that medicines and medical supplies are exempt supplies to Cuba are banned from landing in the USA from the US embargo and can be sold to Cuba. The USA insists, however, that it must be able to verify their proper The Helms-Burton Act, which was passed in March, distribution.10 This provision, and the other bureaucratic 1996, is having an inhibiting effect on non-US medical requirements implemented by the US Government, companies. For example, the Act instructs US officials to effectively subverts the medical-supply exception to the bar US entry to “any alien”—non-US medical company embargo. In essence, the USA remains in violation of directors as well as their families and children—who prisoners, and excessive use of force by police.16 In The US Government acknowledges that there is no addition, it should be noted that Washington has been exemption for food items; it simply notes that there are deemed to have exaggerated Cuba’s abuses of human “ample suppliers” of foodstuffs elsewhere, that Cuba rights, to the extent of codifying such claims into US receives donations of food, and that the food shortages are law.17 These reports should be borne in mind when the not due to the embargo, but, rather, are caused by the US blockade of food and medicine to Cuba is considered.
“Regime’s failure to alter Cuba’s inefficient centralised I thank Victor Sidel, Robert Miller, Wayne Smith, and Robert Bedford for their help with this study and in the preparation of this report.
This argument rings hollow. First, even if Cuba can buy food elsewhere, the inclusion of food in the US trade embargo remains in violation of international law.
1 Carter T. Aid sees embargo over if Cuba reforms. Washington Times. Second, a small amount of food is donated by US organisations,4,10 but that is a poor substitute for removing 2 Redwood H. Price regulation and pharmaceutical research. Oldwicks provisions that prohibit its sale. Third, although Cuba can Press: Felixstowe, Suffolk, UK, 1994.
3 Pharmaceutical Research and Manufacturers of America. World class buy food elsewhere, it must often pay higher drugs: origin of 97 “globalized” drugs 1975–1989. Washington, DC: transportation costs than would be the case with the Pharmaceutical Research and Manufacturers of America, 1994. Citing nearby USA. Fourth, in 1992, the US Government PE Barral. Fifteen years of results of pharmaceutical research in theworld. Paris: Perspective et Santé Publique, 1990.
ignored the warning of the American Public Health 4 US Senate hearing before the subcommittee on western hemisphere Association that the tightening of the embargo would lead and peace corps affairs. Washington DC: Government Printing Office, to an abrupt cessation of supplies of food and medicine to Cuba resulting in widespread “famines”.4 In fact, 5 5 Cuban Democracy Act appears at title XVII 1993 National Defense months after the passage of the Act the worst epidemic of 6 Kirkpatrick A. Medicine and the US embargo against Cuba. JAMA neurological disease this century due to a food shortage 1996; 275: 1633–37.
became widespread in Cuba.12 More than 50 000 of the 7 Embargo violations cost drug maker. USA Today, Oct 25, 1995: 3A.
11 million inhabitants were suffering from optic 8 Helms-Burton Act, Pub L No. 104–114, March 12, 1996.
neuropathy, deafness, loss of sensation and pain in the 9 Walte J. US urged to ease Cuban embargo. USA Today. March 7.
extremities, and a spinal disorder that impaired walking 10 United States Permanent Mission of the Organization of American and bladder control.11–13 Furthermore, as recently as States. ARA press guidance; Cuba: position of Inter-American November, 1995, WHO reported more people with Commission on Human Rights. Washington, DC: United States neurological disease in Cuba due to malnutrition.14 Permanent Mission to the Organization of American States, March 3,1995.
In June, 1993, a delegation sponsored by the American 11 The Cuba Neuropathy field Investigation Team. Epidemic optic Public Health Association travelled to Cuba to assess the neuropathy in Cuba: clinical characterization and risk factors.
impact of the embargo on the public health of the Cuban N Engl J Med 1995; 333: 1176–82.
people. The Association’s report notes that the policies of 12 Roman GC. Epidemic neuropathy in Cuba: a plea to end the United States economic embargo on a humanitarian basis. Neurology 1994; 44:
the Castro regime give a high priority for health care, which has contributed to a large reduction in infant 13 Roman GC. On politics and health: an epidemic of neurologic disease mortality and improvements in health. However, the in Cuba. Ann Intern Med 1995; 122: 530–33.
Association found that the tightening US embargo, 14 Monmaney T. Politics of an epidemic. Los Angeles Times. Nov 20, through the enactment of the CDA, has been associated 15 American Public Health Association. The politics of suffering: the with a decline in the health of the Cuban people.15 impact of the US embargo on the health of the Cuban people.
The US Government often speaks of violations of Washington DC: American Public Health Association, 1993.
human rights in Cuba. Such claims should perhaps be 16 Amnesty International. United States of America: human rights viewed against the background of an Amnesty violations: a summary of Amnesty International’s concerns. London,UK: Amnesty International, 1995.
International report, which catalogues human-rights 17 Human Rights Watch/Americas. Cuba: improvements without reform.
abuses in the USA, such as torture, ill-treatment of Washington, DC: Human Rights Watch/Americas, 1995.


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