A Report from the American Association for World Health
















This study was made possible through the generous support of:

The Arca Foundation, the Christopher Reynolds Foundation, the General Services Foundation, the John D. and Catherine T. MacArthur Foundation.

The American Association for World Health

The American Association for World Health (AAWH) was founded in 1953 as a private, nonprofit charitable and educational organization, and serves as the U.S. Committee for the World Health Organization (WHO) and the Pan American Health Organization (PAHO). Its purposes are to inform the American public about major health challenges that affect people both here and abroad, and to promote cooperative solutions that emphasize grassroots involvement. In carrying out its mission, AAWH works with a variety of public and private health-related organizations, including the Department of Health and Human Services/Centers for Disease Control and Prevention, as well as with WHO and PAHO. AAWH's work is supported by dues payments from institutional and personal members, by charitable contributions from corporate sponsors, and by foundation grants. Guidance is provided by the association's officers and board of directors.

Peter G. Bourne, M.D.
Chairman of the Board American Association for World Health

President Jimmy Carter
Honorary Chairman

Peter G. Bourne, M.D.
Chairman of the Board

Richard L. Wittenberg
President and Chief Executive Officer

Dennis F. Keller, J.D.
General Counsel board of directors

Elizabeth Frawley Bagley, J.D.
U.S. Ambassador to Portugal Lisbon, Portugal

Larry Baum
Senior Vice President, Community Relations Cedars-Sinai Medical Center Los Angeles, California

Charles H. Epps, Jr., M.D.
Vice President for Health Affairs Howard Univ. College of Medicine Washington, D.C.

Mary Joy Jameson
Vice President, Communications American Forest & Paper Association Washington, D.C.

Lucinda Eyster Long
Director, Public Policy Wyeth-Ayerst Laboratories St. Davids, Pennsylvania

Joseph L. Motter
Vice President Macro International Calverton, Maryland

J. Patrick Nicholson
Chief Executive N-Viro Energy Systems, Ltd. Toledo, Ohio

Artemis P. Simopoulos, M.D.
President Center for Genetics, Nutrition & Health Washington, D.C.

Eliot Sorel, M.D.
President World Association for Social Psychiatry Washington, D.C.

Elisabeth A. Squeglia, J.D.
Attorney Bricker & Eckler Columbus, Ohio

Stephen L. Ummel
National Advisor on Integrated Delivery Systems, Ernst & Young LLP Chicago, Illinois

1825 K St., NW, Suite 1208 | Washington, DC 20006 | Telephone 202-466-5883

The U.S. embargo against Cuba has been in place since the early 1960s. It is one of the few embargoes of recent years that explicitly includes foods and medicines in its virtual ban on bilateral commercial ties. Prompted by our 40-year commitment to international health, especially in the developing world, and by the tightening of the embargo since 1992, the American Association for World Health (AAWH) launched a study of the impact of U.S. policy on the health of the Cuban population.

Over a twelve-month period between 1995 and 1996, a multi-disciplinary research team traced the implications of embargo restrictions on health care delivery and food security in Cuba. The team reviewed key U.S. regulations and their implementation, conducted a survey of 12 American medical and pharmaceutical companies and documented the experience of Cuban import firms with the embargo. The team assessed the impact of U.S. sanctions on health in Cuba through on-site visits to 46 treatment centers and related facilities; it conducted 160 interviews with medical professionals and other specialists, government officials, representatives of non-governmental organizations, churches and international aid agencies. In October 1996, the AAWH sent a delegation of distinguished medical experts to Cuba to validate the findings of the draft report through first-hand observation.

The full report of more than 300 pages is the first comprehensive study of its kind. We are pleased to make it available to those who wish more detailed information than this Executive Summary offers. Neither document includes specific policy recommendations. Both are intended to provide a factual basis for informed decision-making on Cuba, and indeed on the wisdom of including food and medicine in any embargo as a means to achieve foreign policy objectives. The AAWH hopes that our findings will temper debate and enhance public knowledge and policy.

Peter G. Bourne, M.D.
Chairman of the Board
American Association for World Health



Summary of Findings

After a year-long investigation, the American Association for World Health has determined that the U.S. embargo of Cuba has dramatically harmed the health and nutrition of large numbers of ordinary Cuban citizens. As documented by the attached report, it is our expert medical opinion that the U.S. embargo has caused a significant rise in suffering - and even deaths - in Cuba. For several decades the U.S. embargo has imposed significant financial burdens on the Cuban health care system. But since 1992 the number of unmet medical needs - patients going without essential drugs or doctors performing medical procedures without adequate equipment - has sharply accelerated. This trend is directly linked to the fact that in 1992 the U.S. trade embargo - one of the most stringent embargoes of its kind, prohibiting the sale of food and sharply restricting the sale of medicines and medical equipment - was further tightened by the 1992 Cuban Democracy Act.

A humanitarian catastrophe has been averted only because the Cuban government has maintained a high level of budgetary support for a health care system designed to deliver primary and preventive health care to all of its citizens. Cuba still has an infant mortality rate half that of the city of Washington, D.C.. Even so, the U.S. embargo of food and the de facto embargo on medical supplies has wreaked havoc with the island's model primary health care system. The crisis has been compounded by the country's generally weak economic resources and by the loss of trade with the Soviet bloc.

Recently four factors have dangerously exacerbated the human effects of this 37-year-old trade embargo. All four factors stem from little-understood provisions of the U.S. Congress' 1992 Cuban Democracy Act (CDA):

  1. A Ban on Subsidiary Trade Beginning in 1992, the Cuban Democracy Act imposed a ban on subsidiary trade with Cuba. This ban has severely constrained 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.

  2. Licensing Under the Cuban Democracy Act, 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. As implemented, the licensing provisions actively discourage any medical commerce. The number of such licenses granted-or even applied for since 1992-is minuscule. 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. This provision has strongly discouraged 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 to 1996, Cuban companies spent an additional $8.7 million on shipping medical imports from Asia, Europe and South America 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.

Taken together, these four factors have placed severe strains on the Cuban health system. The declining availability of foodstuffs, medicines and such basic medical supplies as replacement parts for thirty-year-old X-ray machines is taking a tragic human toll. The embargo has closed so many windows that in some instances Cuban physicians have found it impossible to obtain life-saving medicines from any source, under any circumstances. Patients have died. In general, a relatively sophisticated and comprehensive public health system is being systematically stripped of essential resources. High-technology hospital wards devoted to cardiology and nephrology are particularly under siege. But so too are such basic aspects of the health system as water quality and food security.

Specifically, the AAWH's team of nine medical experts identified the following health problems affected by 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 numbering in the tens of thousands. By one estimate, daily caloric intake dropped 33 percent between 1989 and 1993.

  2. Water Quality The embargo is severely restricting Cuba's access to water treatment chemicals and spare-parts for the island's water supply system. This has led 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 & Equipment Of the 1,297 medications available in Cuba in 1991, physicians now have access to only 889 of these same medicines - and many of these are available only intermittently. Because most major new drugs are developed by U.S. pharmaceuticals, 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, and an AIDS vaccine currently under-going clinical trials with human volunteers.

Finally, the AAWH wishes to emphasize the stringent nature of the U.S. trade embargo against Cuba. Few other embargoes in recent history - including those targeting Iran, Libya, South Africa, Southern Rhodesia, Chile or Iraq - have included an outright ban on the sale of food. Few other embargoes have so restricted medical commerce as to deny the availability of life-saving medicines to ordinary citizens. Such an embargo appears to violate the most basic international charters and conventions governing human rights, including the United Nations charter, the charter of the Organization of American States, and the articles of the Geneva Convention governing the treatment of civilians during wartime.



The Human Toll

AAWH visited a pediatric ward then on its 22nd day without metoclopramide HCI. Without this drug's nausea-preventing effects, the 35 children in the ward undergoing pediatric chemotherapy were vomiting an average of 28-to-30 times a day. The cost of the embargo in human terms can be calculated both statistically and anecdotally. Here are some highlights from the report:
  • Surgeries dropped from 885,790 in 1990 to 536,547 in 1995, a glaring indicator of the decline in hospital resources. Surgical services face shortages of most modern anesthetics and related equipment, specialized catheters, third generation antibiotics and other key drugs, sutures, instruments, fabric for surgical greens, air conditioning equipment 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 (ADD), for instance, increased from 2.7 per 100,000 inhabitants in 1989 to 6.7 per 100,000 inhabitants in 1994. Amebic and bacillary dysentery morbidity rates showed marked increases during the same period.

  • The U.S. embargo is limiting the access of Cuban AIDS patients to a variety of medicines. The AAWH found that the embargo was 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 the time to wait."

  • AAWH visited a pediatric ward then on its 22nd day without metoclopramide HCI, a drug used in combination with others such as betamethasone for pediatric chemotherapy. Without this drug's nausea-preventing effects, the 35 children in the ward were vomiting an average of 28-to-30 times a day.

  • Heart disease is the number one cause of death in Cuba. Mortality rates for men and women have increased since 1989: with 189.3 deaths per 100,000 in 1989 and 199.8 deaths per 100,000 in 1995. In one instance Cuban cardiologists diagnosed a heart attack patient with a ventricular arrythmia. He required an implantable defibrillator to survive. Though the U.S. firm CPI, which then held a virtual monopoly on the device, expressed a willingness to make the sale, the U.S. government denied a license for it. Two months later the patient died.

  • In 1993 the U.S. Treasury Department denied a license, ostensibly for reasons of foreign policy, to the German subsidiary of Pfizer to sell Cuba one pound of the active ingredient methotrexate for trials of an anti-cancer drug.

  • Some 48 percent of the 215 new U.S. medications in phase 1-111 FDA trials in 1995 are specifically for breast cancer. None will be fully accessible to Cuban women as long as the embargo remains in place.

  • Cuban children with leukemia are denied access to new, life-prolonging drugs. For example, the FDA has already approved Oncaspar (pegaspargase), patented by the U.S. company Enzon for patients allergic to L-Spar (l-asparaginase). Both drugs produce longer remission when included in treatment for lymphoblastic leukemia (ALL). However, L-Spar has an allergy rate of 40 percent for first-time use and 70 percent for relapsed ALL patients. Further, Oncaspar is less traumatic to a child suffering from ALL, since it requires only one-sixth the number of injections of L-Spar. But the embargo deprives Cuban children of this innovation. Left untreated, this type of leukemia is fatal in two to three months.

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



Chronology of the U.S. Embargo

1960 March 1960: President Dwight D. Eisenhower approves a plan of covert action and economic sabotage against Cuba. In the first months of 1960, the U.S. government waged a campaign to prevent Cuba from receiving loans and credits from Western European and Canadian institutions. A consortium of European banks, under pressure from the U.S., canceled plans to negotiate a $100 million loan to Cuba.

July 1960: President Eisenhower canceled the unfulfilled balance of the Cuban sugar quota to the U.S. for 1960.

August 1960: Cuba issued Resolution Number 1 under Law 851 which ordered the expropriation of twenty-six of the largest United States companies operating in Cuba.

October 1960: In what the media describes as a "quarantine" of Cuba, the Eisenhower Administration bans U.S. exports to that country - except for foodstuffs, medicines, and medical and hospital supplies. Companies wishing to sell such goods to Cuba can do so under a "general" license (i.e. no specific license application is required). Imports from Cuba continue to be allowed.

1961 January 1961: The U.S. severs diplomatic relations with Cuba.

April 1961: The Bay of Pigs invasion is launched.

September 1961: The Foreign Assistance Act of 1961 authorizes the President to establish and maintain "a total embargo upon all trade between Cuba and the U.S."

1962 February 1962: The Kennedy Administration extends the embargo to prohibit Cuban imports into the U.S.

March 1962: The embargo is further tightened to prohibit imports into the U.S. from third countries of goods made from or containing Cuban materials.

August 1962: In order to dissuade third countries, Congress amends the Foreign Assistance Act of 1961 to prohibit U.S. assistance "to any country which furnishes assistance to the present government of Cuba."

1963 February 1963: President John F. Kennedy prohibits U.S. government-purchased cargoes from being transported on foreign flag vessels which after January 1, 1963, had called at a Cuban port.

July 1963: The U.S. Treasury Department produces the Cuban Assets Control Regulations. These regulations embody the essential features of the U.S. economic embargo against Cuba that has been in effect ever since, including a freeze on all Cuban-owned assets in the United States and a prohibition on all non-licensed financial and commercial transactions between Cuba and the United States and between Cuban and U.S. nationals (including the spending of money by U.S. citizens in the course of travel to Cuba).

1964 May 1964: The Commerce Department revokes its prior general license policy for export to Cuba of foods, medicines and medical supplies. The Commerce Department adopts a broad policy of denying requests for commercial sales of food and medicine to Cuba and permits only limited humanitarian donations.

July 1964: The Organization of American States (OAS) passes a resolution obliging its members to enforce a collective trade embargo on Cuba. The resolution excludes sales of foodstuffs, medicines and medical equipment. The United States, however, persists in its policy of denying licenses for such sales.

1974 July 1974: The Treasury Department liberalizes its Cuban regulations, among other things, to allow the importation of Cuban books and records and to liberalize restrictions on travel to Cuba by scholars and journalists.
1975 July 1975: The OAS repeals its regional trade embargo against Cuba, prompting the Ford Administration to end the ban on third-country subsidiary trade with Cuba and instead requiring only that U.S. companies obtain individual licenses for transactions involving their overseas subsidiaries.

March 1977: The Carter Administration removes restrictions on travel to Cuba by U.S. citizens.

1982 April 1982: The Reagan Administration severely restricts the travel of U.S. citizens to Cuba.
1992 October 1992: President George Bush signs the Cuban Democracy Act (CDA) which outlaws subsidiary trade with Cuba and imposes severe restrictions on foreign ships that visit Cuba before attempting to enter U.S. ports. The CDA also gives the Treasury Department for the first time the authority to levy civil fines up to $50,000 for violations of the embargo.
1996 March 1996: The Cuba Liberty and Democratic Solidarity Act (the "Helms-Burton Act") becomes law. The Act seeks to impede economic recovery under the present Cuban government by deterring foreign investment. Among other measures, the Helms-Burton Act allows foreign companies to be taken to court in the United States if they are "trafficking" in former U.S. citizen-owned properties in Cuba nationalized by the government of President Fidel Castro. ("Trafficking" is expansively defined to include not just direct investment in such properties but also any activities involving such properties that "benefit" the so-called "trafficker.") In addition, the Act "codifies" the existing Cuban Asset Control Regulations. Any modification of those regulations is intended, henceforth, to require an act of Congress.



Current Embargo Restrictions

The bulk of U.S. prohibitions against trade with Cuba are set forth in regulations enforced by the Treasury Department's Office of Foreign Assets Control and the Commerce Department's Bureau of Export Affairs. These include a ban on U.S. exports to Cuba, Cuban imports into the U.S. and even third-country U.S. subsidiary transactions with Cuba. Also banned are family remittances, credits and the transfer of money or property by U.S. nationals to Cuban nationals.
Several provisions of the U.S. embargo constitute major obstacles to any kind of medical commerce for humanitarian purposes,

Several provisions of the U.S. embargo constitute major obstacles to any kind of medical commerce for humanitarian purposes:

  • Direct flights between the two countries are banned.

  • Entry is denied to U.S. ports by any ship which has docked in Cuba during the prior 180 days. U.S. ports are also closed to third-country vessels carrying "goods in which Cuba or Cuban nationals have an ‘interest' whatever the cargo's origin or destination. This prohibition applies to a third-country vessel carrying third-country goods which incorporate even trace amounts of Cuban-origin products or produce."

  • Re-exports to Cuba of U.S.-origin goods and technical data are banned.

  • Exports are banned to Cuba by third-country companies of goods containing 20% or more U.S.origin components; individual licenses are required for those goods containing over 10% U.S-origin components.

    On paper a procedure exists under which application can be made to the U.S. Departments of Treasury and Commerce for licenses to sell (or even donate) medicines and medical equipment to Cuba. In reality, these licensing procedures are a charade. Ostensibly, licensing should have opened a window in the embargo for medical commerce. As implemented, however, by the Treasury and Commerce Departments, licensing has closed this window. The complexity of these procedures and their arbitrary interpretation have created inordinate delays and costs which pose an insurmountable obstacle to commercial interests. For all practical purposes an absolute ban exists on sale of medicines and medical equipment to Cuba by U.S. companies and their foreign subsidiaries. Licenses are also required for humanitarian donations that can only go to non-governmental organizations, of which there are very few in Cuba. Under no circumstance is the sale of food authorized.



Cuba's Health and the Embargo

Such a stringent embargo, if applied to most other countries in the developing world, would have had catastrophic effects on the public health system. Cuba's health-care system, however, is uniformly considered the preeminent model in the Third World.

The Cuban constitution makes health care a right of every citizen and the responsibility of the government. The system is based on universal coverage and comprehensive care, essentially free of charge to the population. Over the years, the central government has placed a top priority on public health expenditures in the national budget and allocated considerable human resources to public health strategies that have earned praise from the World Health Organization, the Pan American Health Organization, UNICEF and other international bodies and individual health care authorities.

Consequently, in the 1990s Cuba's health statistics more closely approximated those of the nations of Europe and North America than of developing countries, with 195 inhabitants per physician, and 95 percent of the population attended by family doctors living in the communities they serve. The infant mortality rate in Cuba is roughly half that in Washington, D.C. Primary care is bolstered with 440 polyclinics; and secondary and tertiary facilities include 284 hospitals and 11 national institutes with inpatient and research capacities.

The infant mortality rate in Cuba is roughly half that in Washington, D.C. Primary care is bolstered with 440 polyclinics; and secondary and tertiary facilities include 284 hospitals and 11 national institutes with inpatient and research capacities.

Selected Health Indicators
Cuba Latin America*
Life Expectancy (1994) 75 years 68 years
Infant mortality (1994) 9.4/1,000 live births 38
Under Five Mortality (1994) 12/1,000 live births 47
Maternal mortality (1980-92) 39/100,000 live births 178
Access to health services 98% of population 73%

*22 countries of the region.

Source: State of the World's Children, 1996, UNICEF. Note that the 1996 figure for Cuba's infant mortality was down to 7.9. While the U.S. embargo has always exerted a negative effect on the Cuban economy, its impact–particularly on the health care system-was significantly ameliorated by Cuba's relationship with the Soviet bloc until the 1980s. Besides the obvious advantages of subsidized trade and aid, the relationship also kept 85 percent of Cuban trade outside the reach of the embargo. Havana's inability to obtain U.S. medical supplies was largely offset by imports from the socialist bloc countries and Western Europe. (Nevertheless, a handful of U.S.-produced drugs still could not be obtained from any other source.) In the 1990s, this situation was dramatically reversed: As the socialist bloc crumbled, the embargo suddenly became extremely effective. After 1989, Cuba lost an annual $4-6 billion in subsidized and bartered trade. Overnight, all imports required hard currency. In a two-year span, the economy contracted by 35 percent, evaporating an annual average growth of 4.3 percent in the previous decade.

Suddenly, Cuba's health system no longer had access to East bloc raw materials for its pharmaceutical industry, and at the same time shortages of hard currency made it increasingly difficult to purchase drugs and medical equipment in Western Europe and elsewhere.

The Cuban Democracy Act (CDA) of 1992 severely aggravated Cuba's ability to purchase drugs and medical equipment by prohibiting foreign subsidiaries of U.S. companies any trade with Cuba. The Cuban Democracy Act (CDA) of 1992, severely aggravated the situation by prohibiting foreign subsidiaries of U.S. companies any trade with Cuba. Ninety percent of that trade was in food and medicines. Business with U.S. subsidiaries had continued to grow well after the Soviet collapse, reaching $718 million in 1991, the last full year before the CDA cutoff.

To compound matters, the CDA prohibitions were enacted during a period when U.S. firms were particularly active in buy-outs and takeovers of third-country medical companies. Many of these companies were prime suppliers to the Cuban health care system. While in some instances Cuba managed to continue such purchases through intermediaries at greatly inflated prices, as a rule Cuban hospitals and physicians had to cope with abrupt cut-offs of key medicines, medical equipment, medical texts, inputs for diagnostics, vaccinations, and pharmaceutical and biotechnology research and development. In 1995, for instance, Upjohn, a major U.S. pharmaceutical company, merged with a Swedish concern, Pharmacia, which since 1970 has logged multimillion dollar sales to Cuba of protein purifying equipment (HPLCs), reagents for clinical laboratories and production plants, chemotherapy drugs, and growth hormones. Though technically Upjohn could have applied for a U.S. export license to continue supplying Cuba with some of these items, the company opted instead to terminate Pharmacia's sales and closed down its Havana office within 3 months of the merger. Cuba suddenly lost another supplier of plates for HIV-tests and other diagnostic kits to screen for hepatitis B and C, when Sybron International of Wisconsin bought out Nunc of Germany. Cuba lost two main sources for pacemakers under similar circumstances.

The human consequences of these decisions are all too evident in the wards of Cuban hospitals.

The human consequences of these decisions are all too evident in the wards of Cuban hospitals. When the AAWH delegation visited the cancer ward at the Juan Manuel Marquez Pediatric Hospital in Havana, our doctors found that oncologists do not have access to U.S.-manufactured cell-site-ports for chemotherapy. (The U.S. is the leading producer of this item.) As a result, nurses and physicians must repeatedly puncture and search for new veins in young children, causing them added pain and suffering. In order to treat one five-year-old girl suffering with sarcoma, doctors were compelled to use the girl's jugular vein because all her other veins had already collapsed. As a result, she developed a hematoma that almost killed her. The child was in excruciating pain. The availability of the cell-site port Implantofix would have prevented the child's suffering. This product, however, is manufactured by Braun Medical, Inc., of Bethlehem, Pennsylvania. Although Braun is associated with a German company and has an affiliate in France, their cell-site-port is produced in the United States and is thus subject to the embargo. The other obvious supplier-indeed, the world market leader in cell-site-ports-is the previously mentioned Swedish-American firm, Pharmacia, which is also covered by the embargo.

Even when Cuba is able to find a third-country supplier of medical equipment, penalties under the embargo have proved to be a serious impediment. The CDA's extraterritorial provision barring entrance to U.S. ports of any ship docking in Cuba during the preceding 180 days has not only impeded normal commercial shipping to the island but cost Cuban importers up to 30 percent more in shipping charges over the World Scale rate. Within months of the CDA's passage, shipping problems caused major delays in deliveries of soap, fuel, powdered milk, cooking oil, wheat, beans, rice and medical supplies. Steeper rates require Cuba to spend more of a limited budget on shipping and less on purchases of food and medicines critical to the welfare of the Cuban population.

Within months of the CDA's passage, shipping problems caused major delays in deliveries of soap, fuel, powdered milk, cooking oil, wheat, beans, rice and medical supplies.

The devaluation of the Cuban peso and general hard currency shortfall reduced dollars for the health sector by 30 percent from 1989 to 1993, the year after the CDA went into effect.

The 1996 Helms-Burton law seeks to discourage foreign investment in Cuba by threatening third-country investors with suits in U.S. courts and by applying sanctions against their executives. The law has had a chilling effect, further discouraging American suppliers in the health care industry from even contemplating trade with Cuba.

The Cuban government has responded to the challenges posed by the stiffened embargo by boosting its health care spending. During the years from 1989 to 1996-a period of general economic trauma-the national budget remained static, but public health outlays nevertheless increased by 30.4 percent, reaching $1.18 billion pesos. This added investment in public health came at the expense of other sectors, such as public administration, defense, culture and the arts. While priority was also afforded to health in hard currency spending, the devaluation of the Cuban peso and general hard currency shortfall reduced dollars for the health sector by 30 percent from 1989 to 1993, the year after the Cuban Democracy Act went into effect. The slow climb to $104.2 million in hard currency expenditures in 1995 remained less than half the 1989 spending levels.

Both the embargo and the hard currency shortfalls have resulted in an acute shortage of medical products. Of the 1,297 medicines in the country in 1991, only 889 can be obtained today, many of them only intermittently. Lack of spare parts has slowed equipment repair and replacements are virtually unobtainable. The Ministry of Health reports, for example, that 13 per cent of Cuba's X-ray machines are out of commission, as are 21 per cent of their cobalt therapy units.

In addition, the nation's health care infrastructure has suffered from diminished access to electricity, oil, diesel and gasoline. Many ambulances and mobile mammography vehicles stand idle for lack of gasoline. Pharmaceutical plants are operating at one third their 1980's levels, and power outages risk spoilage of medications and vaccines in refrigerated warehouses and threaten the lives of patients in the midst of surgery.

Lack of spare parts for U.S.-outfitted water treatment plants, and shortages of chlorine, detergents and disinfectants have led to an increase in water-borne disease, with higher mortality rates among the elderly; outbreaks of scabies and other dermatological disorders are on the rise, as are incidents of hospital infections and sepsis.

Sharp declines in food imports and inputs for agriculture have resulted in significant signs of nutritional deficits, most notably in the 1993 neuropathy epidemic that temporarily blinded over 50,000 Cubans. Workplace and school dining halls serve fewer calories and less protein, while the daily liter of milk once assured to all children up to age 13 is now limited to children through age 6. The population over 65 no longer receives special dietary supplements.

Quite clearly, Cuba's health care delivery system has been severely weakened, particularly at the secondary and tertiary levels of care. Only the pre-existing excellence of the system and the extraordinary dedication of the Cuban medical community have prevented infinitely greater loss of life and suffering.


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