In 1989, the World Health Organization extolled Cuba's health care system as a "model for the world." Cuba, with its nutritional safety net, extensive system of family doctors and sophisticated tertiary care facilities, had achieved the highest quality of life indicators in Latin America, including an infant mortality rate 30 points below the average, on a par with the developed world.

But now, ten years later, according to two recent studies by the American Public Health Association (APHA) and the American Association for World Health (AAWH), the Cuban people, especially the children, are now facing dangerous shortages of medicines and medical supplies. Although some of the blame can be placed on the dissolution of the Soviet bloc countries and inefficiencies within Cuba, the APHA and the AAWH find that the fault lies primarily with the U.S. embargo of Cuba.

The AAWH's team of nine medical experts attributed the following Cuban health problems directly to the embargo:

1. Malnutrition -- The outright ban on the sale of American foodstuffs has contributed to serious nutritional deficits, particularly among pregnant women, leading to an increase in low birth weight babies. In addition, food shortages were linked to a devastating outbreak of neuropathy in 1993-94 affecting the tens of thousands. By one estimate daily caloric intake dropped 33 percent between 1989 and 1993

2. Water Quality -- The embargo severely restricts Cuba's access to water treatment chemicals and spare parts for the island's water supply system, leading to serious cutbacks in supplies of safe drinking water, which in turn has become a factor in the rising incidence of morbidity and mortality rates from water borne diseases.

3. Medicines and Equipment -- Of the 1,297 medications available in Cuba in 1991, physicians now have access to only 889, and many of these are available only intermittently. Because most major new drugs are developed by U.S. companies, Cuban physicians have access to less than 50 percent of the new medicines available on the world market. Due to the direct or indirect effects of the embargo, the most routine medical supplies are in short supply or entirely absent from some Cuban clinics.

4. Medical Information -- Though information materials have been exempt from the U.S. trade embargo since 1988, the AAWH study concludes that in practice very little such information goes into Cuba or comes out of the island due to travel restrictions, currency regulations and shipping difficulties. Scientists and citizens of both countries suffer as a result. Paradoxically, the embargo harms some U.S. citizens by denying them access to the latest advances in Cuban medical research, including such products as meningitis B vaccine, cheaply produced interferon and streptokinase.

The cost of the embargo in human terms can be calculated both statistically and anecdotally:

AAWH visited a Cuban pediatric ward then on its 22nd day without the nausea-preventing drugs normally used in chemotherapy. The 35 children in the ward were vomiting an average of 28-30 times a day.

Cuban children with lymphoblastic leukemia are denied access to new life-prolonging drugs, such as oncaspar, patented by a U.S. company, that produces longer periods of remission and is less traumatic to the child patient, requiring only one sixth the number of injections. Left untreated, this type of leukemia is fatal in two to three months.

Pediatric-size needles for intravenous chemotherapy and glucose are in short supply, necessitating puncturing children's tiny veins with adult sized needles.

Surgeries dropped from 885,790 in 1990 to 536,547 in 1995, a glaring indicator of the decline in hospital resources such as most modern anesthetics and related equipment, specialized catheters, and disposable supplies.

The deterioration of Cuba's water supply has led to a rising incidence of water borne diseases such as typhoid fever, dysenteries and viral hepatitis. Mortality rates from acute diarrheal disease, for instance, increased from 2.7 per 100,000 inhabitants in 1989 to 6.7 in 1994. Children are disproportionately affected by such disorders.

The embargo is directly responsible for up to six month delays in AZT treatment for a total of 176 HIV patients in Cuba at a time when AZT was the only approved medication heralded for slowing the progress of the virus. As one AIDS professional told the AAWH, "The problem is that our patients don't have time to wait. innovation.

In general the embargo effectively bans Cuba from purchasing nearly one half of the new world class drugs on the market.

Four specific contributory factors of the embargo have been sited:

1. Ban on Subsidiary Trade
   The 1992 Cuba Democracy Act (CDA) imposed a ban on subsidiary trade with Cuba, severely constraining Cuba's ability to import medicines and medical supplies from third country sources. Moreover, recent corporate buy-outs and mergers between major U.S. and European pharmaceutical companies have further reduced the number of companies permitted to do business with Cuba. Prior to the passage of this Act, Cuba did over $700,000,000 worth of trade with U.S. subsidiaries, 90% of which was for food and medicine.

2. Licensing
   Under the CDA, the U.S. Treasury and Commerce Departments are allowed in principle to license individual sales of medicines and medical supplies, ostensibly for humanitarian reasons to mitigate the embargo's impact on health care delivery. In practice, according to U.S. corporate executives, the licensing provisions are so arduous as to have had the opposite effect, actively discouraging any medical commerce. The number of such licenses granted - or even applied for - since 1992 is miniscule. Numerous licenses for medical equipment and medicines have been denied on the grounds that these exports "would be detrimental to U.S. foreign policy interests."

3. Shipping
   Since 1992, the embargo has prohibited ships from loading or unloading cargo in U.S. ports for 180 days after delivering cargo to Cuba, strongly discouraging shippers from delivering medical equipment to Cuba. Consequently shipping costs have risen dramatically and further constricted the flow of food, medicines, medical supplies and even gasoline for ambulances. From 1993-1996, Cuban Companies spent an additional $6.7 million on shipping medical imports from Asia, Europe and South American rather than from the neighboring United States.

4. Humanitarian Aid
   Charity is an inadequate alternative to free trade in medicines, medical supplies and food. Donations from U.S. non-governmental organizations and international agencies do not begin to compensate for the hardships inflicted by the embargo on the Cuban public health system. In any case, delays in licensing and other restrictions have severely discouraged charitable contributions from the U.S.

Recommendation:
The United States should cease measures that exacerbate the food and medicine crisis in Cuba. Restrictions on the sale and shipping food and agricultural supplies and of medicines and medical equipment, should be lifted. In the current Congress, legislation to this effect will be introduced by Representatives Rangel and Serrano and Senators Dodd and Warner. President Clinton should actively work with Congress to pass these bills this year.

See: Legislative Action Alert