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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