date to maintain those gains in health are further evidence of a successful system of health care. However, those gains are in jeopardy. Two weeks ago I returned from a 7-day visit to Cuba as part of the third APHA delegation in three years to travel there to learn more about the Cuban health infrastructure and to assess the continued impact of the U.S. embargo and the recently enacted Cuban Democracy Act of 1992. The adverse effects on the lives of the Cuban people are quite visible. Of most concern to the public health delegation were the significant shortages of food, medicines, and medical equipment. Since 1988, as a result of the loss of preferential trade relations with the former Soviet Union and its allies, imports and exports from Cuba have declined precipitously and the Gross Domestic Product may have plummeted by 40%. This has inevitably reduced resources available for health and medicine. of greatest concern is the availability of foodstuffs to the population. About half of all proteins and calories intended for human consumption have been imported in the past; importation of foodstuffs has declined by about 50% in the last four years. Reduced imports and a shift toward lower quality protein products is a significant health threat. Per capita protein and calorie availability declined 3% in 1989 and have continued to decline in each year since. This is associated with a rise in the percentage of babies born with inadequate weights, from 7.3% to 8.7% (See figure 2). The percentage of women with inadequate weights when they become pregnant and with inadequate weight gains during pregnancy are also on the rise (See figure 3). Undernutrition was a major risk factor in the epidemic of optic neuropathy which attacked the country in 1993 and 1994. A lack of materials for water systems has resulted, for the first time in thirty years, in a reversal of the trend toward universalization of household connections for potable water (See figure 4). of greater concern are disruptions in supply and production in the chemical industry. These have left the country with a serious deficit in materials to treat water (see figure 5), resulting in a decline in the quality of water available. Combined with fuel and parts shortages which reduce the country's ability to collect and dispose of solid wastes, these threats are associated with a rise in both the incidence and death rate from acute diarrhea and other parasitic diseases (see figure 6). Nutritional factors as well as crowding and deteriorating sanitation may be responsible for a recent rise in Tuberculosis cases, the first such rise to occur in decades. Many efforts are being made to minimize the impact of this situation on health. Health education and changes in hospital organization have been very successful in increasing the rate of exclusive breast feeding, from 63% in 1990 to 91% in 1993, thus minimizing the impact of the nutritional crisis on newborns. Reduced supplies of high quality foods are being prioritized to most vulnerable populations. Distribution of critical goods is facilitated by a rapid expansion in preschool enrollments during the 1990s. These efforts, along with high educational levels, wide and easy access to primary and secondary health services, and a high continuing financial commitment (see figure 7) to provide medical services has thus far prevented these threats from resulting in a deterioration of the overall population's health. The number of physicians and hospital beds per capita continue to rise (see figure 8). Per capita outpatient visits are stable, and the rate hospitalizations has declined mainly due to improved primary Indeed, if transportation were not critically short, it is believed that the number of hospitalizations would decline of care. further. These factors, taken together, help to explain the apparently contradictory situation of rising infectious diseases and low birth weight, and continuing reduction of already low rates of infant, maternal (see figure 9), and total mortality. These benefits to the general population come at a cost which has been greatly exacerbated by the embargo in recent years. The ability of Cuba to import food, medicines, and medical supplies has been greatly reduced (see figure 10). Some essential medicines and supplies are only produced in the U.S. These used to be available from third countries at increased cost and with significant delays. Some, like the only effective treatment for a pediatric leukemia, X-ray film for breast cancer detection, U.S.-made replacement parts for otherwise European-made respirators, and medical books from a firm recently bought by a U.S. conglomerate, can no longer be purchased at all. Most medical materials are produced in other countries, but cost an average of 30% more and require 50% to 400% greater shipping charges than would the same goods purchased in the U.S. Long supply lines and increased middlemen mean that some sensitive materials are inappropriate or useless by the time they arrive, including $50,000 worth of reagents for prenatal testing of genetic diseases. In a move which goes beyond the Torricelli legislation, third countries have been convinced by the U.S. State Department to forego the sale of goods as basic as soap in order to preserve good trade relations with the much bigger U.S. market. Cuban imports from U.S. subsidiaries prior to the implementation of the Torricelli legislation accounted for only a small portion of Cuban imports, but 75% of it was for foods and medicines destined for the direct relief of suffering and meeting of basic needs. U.S. embargo legislation against all other countries during the last two decades has included exemptions for such humanitarian purposes. It is ironic that the one country singled out for such a cruel embargo is one which has demonstrated an exemplary commitment to meeting basic human needs. The U.S. should not, and according to customary international law cannot, punish Cuban citizens in this way. |