Cuban health care and the U.S. embargo

Since the revolution Cuba has developed a remarkable and successful health care system unmatched in the third world. In developing a social policy that provides health care for all its citizens while at the same time organizing a pharmaceutical and biotechnology industry that is as resourceful as it is inspiring Cuba has made advances in medicine admired throughout the world. As The Economist maintained in 1996 "Cuban medicine is disciplined and innovative.... Cuban research establishments have made breakthroughs in vaccines, immunology and biotechnology."(1) The sophisticated nature of the medical establishment is evident as one travels the island visiting medical facilities, as I did in a series of visits between 1995 and 1997. The progress made by Cuba, particularly while under the constant harassment of the U.S. embargo, is really quite staggering and it is the purpose of this discussion to expand upon Cuba's medical program within the context of the embargo.

Labeling Cuba a threat to U.S. national security has provided Washington with the rationale to include medicine and basic food within the framework of the embargo making it "abundantly clear that economic sanctions are, at their core, a war against public health."(2) Indeed, because the embargo prohibits products that contain any U.S. component or material from being exported to Cuba from third countries, including products based on U.S. design and technology, and because most major new drugs are developed by U.S. pharmaceutical companies, Cuba has access to only a small percentage of the new medicines available on the world market.(3) The embargo as it affects medicine, scientific technology, textbooks and periodicals is a virtual world-wide blockade vigorously enforced by the United States. The minutia of enforcement, according to the New England Journal of Medicine, "are all-encompassing. The interdicted trade includes visits by medical delegations and the mailing of medical journals...."(4)

Because of the embargo the Cuban health care system exists within a frame of political and social contradiction. It is one of the jewels of the revolution, yet it is handicapped by the fierceness of the embargo and the fury of U.S. enforcement. While developing innovative medicines, and techniques for delivery of services, the Ministry of Public Health and hospitals must literally shop around the world paying exorbitant rates to obtain supplies, often secretly, that are, quite simply, available but unaccessible ninety miles away. In 1991 then U.N. Ambassador Ricardo Alarcon argued that the "U.S. embargo has caused Cuba substantial material losses. Total prohibition of Cuba's acquisition of foodstuffs, medicine and medical supplies and equipment of United States origin ... has caused and still causes appreciable additional harm to the Cuban people."(5) This remains the case today.

A major issue of importance then is to analyze the structure of the Cuban health care system, and to indicate its extraordinary accomplishments while examining what the United States is doing to try to destroy Cuba's public health organization. This will clarify the political impediments Cuba must deal with to continue providing a public health care program that is closely integrated with the development of medicines through biotechnology and the more traditional pharmacology.

Technology and Comprehensive Health Care

A country with merely 11 million people, Cuba has become a powerhouse of medical innovation. In this small country there are 284 hospitals, 440 clinics, 11 research institutes, and 15 medical colleges, while with some 60,000 doctors and more than 5000 researchers the "national average ratio of physicians to total population is one doctor for every 180 people, and this does not count ... nurses, physical therapists, medical technicians and medical researchers."(6) All physicians must complete a nine year medical program with formidable medical standards and an additional three years of study for specialization.

Cuba's primary research facilities are located in Havana, the most prominent being the Centro de Ingenieria Genetica y Biotecnologia (CIGB) which was organized in 1986. Located on the outskirts of Havana this complex has developed a large quantity of medical products for Cubans while also exporting its innovative medical technology abroad. The sixth largest currency earner, exports of diagnostic equipment and pharmaceuticals earned Cuba $120 million in 1995.

Using a new combination of genes, researchers at CIGB have developed a recombinant vaccine against hepatitis-B or serum hepatitis which is caused by a DNA virus. Cuba is presently the sole producer of a vaccine against the bacteria that cause meningitis-B. While the highly renowned and esteemed Cuban Institute of Hematology uses molecular biology in the treatment of leukemias and lymphomas, CIGB developed a process to extract interferon from leukocytes to treat such cases. A microsurgical approach to cure retinitis pigmentosa, a genetic disorder causing a degeneration of the retina leading to tunnel vision or total blindness and affecting one out of every four thousand people world-wide, has been developed with an 80 percent success rate. Vitiligo, the loss of skin pigmentation, regarded heretofore as untreatable, is successfully being treated by newly developed substances that evolved from research at the Placental Histotherapy Center. The remission rate in severe cases is some 80 percent. Havana's International Center for Neurological Restoration is one of the world's leading centers for the treatment of Parkinson's disease. Research on the development of a vaccine against AIDS has been under way for years with testing on humans presently ongoing.(7) Scientists have also emphasized improving the food supply which directly affects the health of the population. Researchers at CIGB "equipped sugarcane with bacterial genes that confer pest-resistance" and "developed a monoclonal antibody to detect tristeza, a lethal virus that threatens to devastate the Caribbean citrus industry."(8)

The medical technology developed by Cuban researchers certainly far exceeds that spawned in other third world countries and in many cases matches, even sometimes surpasses, developments in the West. Breakthroughs have been made and the results are impressive, to say the least.(9) The significance of Cuba's initiatives in this area is matched by its public health care system and the attention devoted to the primary health of its citizens. Impressive too is the fact that the United States, in violation of any human rights standard, is doing what it can to spoil, even destroy the medical advances made by Cuba, and that whatever success is achieved is accomplished despite the menacing effects of the Cuban embargo.

In 1959 Cuba created a universal, comprehensive and free-to-the-patient health care system, granting each citizen the right to all available health care. According to the 1976 Cuban Socialist Constitution health care is considered a fight available to Cuban citizens, and medical care along with food, clothing, housing and education is "of the highest priority."(10)

Under the authority of the Ministry of Public Health free medical and health care is provided through a network of doctors, clinics and hospitals supplemented by the pharmaceutical and biotechnology industry. Each urban neighborhood has a community clinic that serves 30,000-40,000 people and offers treatment for minor ailments. These clinics are in many cases integrated with maternity homes that offer pre-and postnatal care. Rural clinics and maternity homes are also dotted throughout the countryside. According to Dr. Michele Frank the maternity homes offer residence to high risk cases, and also offer meals and vitamin supplements to outpatients to increase birth weights.(11) Family doctors are located in each neighborhood throughout the country. Using both the clinics and medical practitioners 98 percent of all children have been vaccinated against twelve major diseases including meningitis-B and hepatitis-B. The vaccines are provided by the biotechnology industry to the clinics, doctors and hospitals and are distributed free of charge. Prescriptions for drugs and antibiotics are filled at state pharmacies, when the medicines are available, at no cost to the patient.

For more serious cases and for treatment of the chronically ill, municipal hospitals exist in all cities. Many of the hospitals are really quite old, having been constructed prior to the revolution, and do not have the up-to-date facilities that are often required. Thus, these hospitals, such as Hospital Calixto Garcia, in Vedado, Havana, service patients whose illnesses are too complex for the clinics but who do not require the services of the more modern hospitals. These antediluvian hospitals are usually made up of only one building, or a series of low-rise structures each associated with a different speciality but with only a limited number of beds available.

The more modern and recently constructed hospitals, such as the Hospital Clinic Quirurgico "Hermanos Ameijeiras" in Central Havana, offer services and treatment in the fields of bacteriology, microbiology, gastroenterology, optomology, dermatology, neurology, oncology, pathology, and trauma, among others. Clean, modern, up-to-date, often high-rise structures, these newer hospitals have a large number of beds that offer private and semi-private facilities not found in the older hospitals. The technology available is also of more recent vintage.

In observing the older hospitals one finds that all the beds are in large, poorly maintained rooms, with no separation between them, while waiting rooms overflow with people, and treatment rooms have little medical stock and are barren of technology. In both old and new facilities specialists in the major fields are usually available though they often do not have the resources to deal capably with their patients. Antibiotics are often unavailable because they have been patented by U.S. firms and thus fall under the restrictions of the embargo. Hospital administrators, through the Ministry of Public Health, must shop around in Europe, Canada or Asia to acquire some medicines, but even if other countries are willing to circumvent the embargo and sell the product it must be paid for in U.S. dollars or other hard currency which is often unavailable given Cuba's many needs. Antibiotics and other medicine developed and produced solely by third countries can be openly and easily purchased.

Cuba has also developed a system of private hospitals providing specialized services for foreigners only. For example, the Centro Internacional de Retinosis Pigmentaria Camilo Cienfuegos, a small hospital in Vedado, Havana, treats retinitis pigmentosa and other eye diseases. People come from all over the world for treatment. Other private hospitals offer medical care and treatment for cancer, skin diseases, open-heart surgery, Parkinson's disease, kidney transplants, and neurological disorders. Fees for such services brought Servimed, Cuba's foreign health agency, $24 million in 1995.(12) No private services are obtainable for U.S. citizens since a license from the U.S. Treasury Department is required for travel to Cuba and is not granted for such purposes.

The private hospital infrastructure is generally superb since the hard currency paid by foreign patients is used to support this network of institutions. In fact they look like private clinics for the wealthy and they are able to obtain almost everything they need in the way of supplies. Seventy percent of the fees remain with the hospitals while thirty percent is turned over to the health ministry to supplement the public health budget. Yet, even the private hospitals must usually deal directly, or through the Ministry of Health, with Canada, Europe, Asia, South America or Israel to locate countries willing to break the embargo so that supplies can be accumulated. The academic administrator of Centro Camilo Cienfuegos told me that the hospital must often engage in such surreptitious purchasing. The public hospitals don't usually have that ability since they don't have the dollars budgeted to satisfactorily do so.

Clearly, a dual class medical system exists to some degree. Foreigners can obtain the best service-for-fee procedures and rarely entertain deficiencies in obtaining medical care. Although similar care is available free for Cubans they often can not obtain it because of the cost involved for Cuba in defying the embargo. Medicine, medical supplies and technology are too often unaccessible.

The Response of the United States

In examining the practice of medicine in numerous hospitals and clinics, and in interviewing medical researchers it has been perceptible to this observer for some years that although the precise effects of the U.S. embargo vis-a-vis health care and medical research may be little known elsewhere they are quite apparent in Cuba.(13)

Because most antibiotics are produced under U.S. patents they can not be exported to Cuba under terms of the embargo. Any third country or foreign enterprise doing so can be slapped with U.S. sanctions. In December 1995 America's largest pharmaceutical corporation announced it would never do business again with Castro's Cuba after sanctions were activated and a stiff fine imposed when Merck provided medical information (and only information) to Cuba. Technology that contains U.S. components or is partially developed by a U.S. firm is also embargoed. In the 1990's this included:

A sale by the Japanese company Toshiba of medical equipment used to detect cardiovascular diseases and blood analysis laboratory equipment from the Swedish firm LKB. U.S. Commerce officials also forbade the Argentine supplier Medix from shipping spare parts needed by Cuban hospitals to maintain U.S.-made dialysis machines and opthalmologic sonar equipment already in use throughout the island.(14)

Waterborne diseases are prevalent in contemporary Cuba because the United States prohibits the sending of equipment to repair U.S.-made water treatment facilities. In 1994 the U.S. Commerce Department denied an export license for X-Ray replacement parts costing less than $175.(15) According to The 1963 Trading With the Enemy Act a license from the U.S. Treasury Department is necessary even to donate medicine to Cuba, and "no vessel carrying goods to or from Cuba ... may enter a U.S. port ... for 180 days."(16) Prior to the passage of the 1996 Helms-Burton Act U.S. citizens with an appropriate license from the Department of the Treasury were permitted to carry medical supplies to Cuba but only if addressed to a single individual or family and only if the travel to Havana was by the daily U.S. chartered flight from Miami. After the imposition of Helms-Burton the flights were eliminated thus cutting Cuba off from all medical supplies brought in via the United States legally.

The Trading With The Enemy Act also prohibits the importation of goods of Cuban origin to the United States including medical innovations unavailable in the United States. In the effort to deprive Cuba of access to U.S. dollars Americans are disallowed from benefiting from Cuban medical innovations and technology either in Cuba or the United States. Those who violate the Cuban Assets Control Regulations may incur penalties of up to ten years in prison, $1,000,000 in corporate and $250,000 in individual fines. In addition foreign corporations whose offices are in nationalized U.S. property in Cuba may have their executives prohibited from traveling to the United States, while they and their corporations may be sued in U.S. courts.

In Cuba the effects of the embargo's prohibitions are pernicious. Pharmacies are largely empty of stock as most antibiotics are either unavailable or in very short supply. Chlorination equipment and replacement parts for water pumping stations purchased decades ago from U.S. companies are laborious to obtain leading to an increase in the incidence of intestinal infections. Chemotherapy drugs, which are largely under U.S. patent, are in short supply. The sale of such commodities is limited under the various acts of the embargo and third countries are hesitant to run afoul of the United States since so much more trade and commerce takes place with it. Because gasoline is in such short supply, and travel is expensive and difficult, patients in the interior often find that they cannot travel to hospitals where services are performed. Everything from film for mammography units to maintaining mobile hospital vans is affected by the embargo. Because Cuba is a poor country, with a limited budget and hobbled by agricultural shortfalls, the embargo's ramifications on the health care system are enormous. According to the New England Journal of Medicine U.S. sanctions were the immediate cause of an epidemic of 50,000 cases of optic and peripheral neuropathy between 1991 and 1993, and the Ministry of Public Health had to initiate a crash program of importing multiple-vitamin supplementation for the Cuban people.(17) Although Cuba seeks to purchase supplies abroad, even when it can the embargo "seriously affects medical costs. Medicuba, responsible for maintaining the island's medical supplies ... spends $6 million for medical air and sea freight alone. If the same products were obtained in nearer markets, transport costs would be only $1 million to $2 million."(18) In sum, according to the American Journal of Public Health "the embargo has contributed to the deterioration in the quality of health care and has exacerbated undernutrition by raising the cost of medical supplies and food to the island."(19)

The Political Ramifications

In January 1997 I met in Havana with Miguel Barnet, the prominent Cuban novelist and folklorist, author of scores of books including Biografia du un Cimarron (Havana: Editorial Academia, 1996, 30th anniversary edition), and Director of the Casa Don Fernando Ortiz Literary Institute. A delightful man still brimming with enthusiasm for the revolution, his discussions with me reflected not only the position of medical and political authorities I met, but what Cubans felt wherever I met them. He made it clear that all Cubans, whether supporters of communism or not, stood in opposition to United States policy, especially as it relates to the embargo of medicine and food. Since all people's health and sometimes their lives are directly affected by this aspect of the embargo most identify themselves as nationalists standing in opposition to U.S. policy.

The embargo of medical technology and medicine has drawn Cuban society together and even enlarged the support of Fidel Castro who is seen as a nationalist standing up to the United States. Barnet insisted that it was vital for the North American public to understand that threatening the health of Cubans was a foreign policy ominous in its implications and would not quickly be forgotten. He reaffirmed time and again that it was essential for North Americans to grasp this point. His argument was significant as it was echoed by all medical personnel I met with. Indeed, most Cuban doctors are paid the equivalent of about $14 per month in pesos. They remain in their positions, as indicated to me, because they are proud to be participants in what amounts to a reformation in health care for Cuba and they are committed to it. Many even volunteer for one year service programs that third world countries contract out to Cuba, such as Angola, and South Africa (where some 600 doctors are presently practicing). These nations request their services because of the international reputation Cuban health care has attained.

Cuba today is not a security threat to the United States. The Cuban populations's health and Cuba's medical technological initiatives are incurring injury because the United States is attempting to prove that communism in Cuba can't work, and it is frustrated in that it has been unable to unseat Fidel Castro through nine different presidencies. But the policy of the embargo is incusing extreme frustration and animosity among Cuban medical personnel and the wider population. Article 25 of the Universal Declaration of Human Rights maintains that everyone has the right to the "health and well-being of himself and his family, including... medical care and necessary social services."(20) An argument can certainly be put forward that the United States is in violation of Article 25 by repressing the right of Cubans to adequate health care.

Cuba has accomplished much in the development of a biotechnology and pharmacology industry directly linked to a public health care program that is remarkably innovative and often successful. It should be applauded for the advances it has made in health care for it has accomplished what no other third world country has, despite the intrusive activities of the United States. Miguel Barnet appears to be correct: the embargo has ominous effects that North Americans would do well to reflect upon.(21) Rather than maintaining a war against public health in Cuba the United States ought to recognize what Cuba has attained. It has advanced a public health record of genuine accomplishment which should be acknowledged rather that discredited via the embargo.

NOTES

1. "One thing Cuba does right," The Economist, September 7, 1996, p.42.

2. Leon Eisenberg, M.D., "The Sleep of Reason Produces Monsters - Human Costs of Economic Sanctions," New England Journal of Medicine, v. 336, no. 17, April 24, 1997, p.1250.

3. Julia Sweig and Kai Bird, "Denial of Food and Medicine: The Impact of the U.S. Embargo on Health and Nutrition in Cuba" (Executive Summary), American Association for World Health, March, 1997, p. 16.

4. New England Journal of Medicine, op. cit., p. 1249.

5. Mary Murray, Cruel & Unusual Punishment: The U.S. Blockade Against Cuba (Melbourne, Australia: Ocean Press, 1993), p.25, Ricardo Alarcon is presently President of the Cuban National Assembly of People's Power and is a member of the politburo.

6. Ralph Alan Dale, "Integrating Natural and Traditional Medicine with Conventional Medicine in Cuba," Cuba Update, Winter 1997, p.22. The United States has one physician for every, 350 people, The American Association for World Health (March, 1997), maintains that "Cuba's health care system is uniformly considered the preeminent model in the third world," p.11.

7. In 1996 the number of HIV-positive cases reported was 1408 of whom 373 died. AIDS patients are removed from the general population and placed in special sanatoriums where they receive extensive medical care.

8. J. Madeleine Nash, "Made in Cuba," Cuba Update, September 1996, p. 20.

9. For additional information on Cuba's medical innovations see Ralph Alan Dale, op. cit.

10. Patricia Ruffin, "Socialist Development and Human Rights in Cuba," in Peter Schwab, Adamantia Pollis, Toward a Human Rights Framework (New York: Praeger Publishers, 1982), p. 123.

11. "A Conversation with Michele Frank, M.D.," Cuba Update, Winter 1997, p. 21.

12. The Economist, op. cit.

13. See also Richard Garfield and Sarah Santana, "The Impact of the Economic Crisis and the US Embargo on Health in Cuba," American Journal of Public Health, January, 1997.

14. Mary Murray, op. cit, p. 26.

15. Malcolm Wallop, "Target Castro, Not Cuba's People," Wall Street Journal, April 24, 1997.

16. What You Need To Know About The U.S. Embargo: An overview of the Cuban Assets Control Regulations, Title 31 Part 515 of the U.S. Code of Federal Regulations, Office of Foreign Assets Control, U.S. Department of the Treasury, 1996, p.1.

17. New England Journal of Medicine, op. cit., p. 1249.

18. Adverse consequences of the economic embargo by the United States of America upon the enjoyment of human rights by the Cuban people, Ministry of Public Health, Havana, 1991. According to The American Association for World Health (March, 1997), the increases in shipping charges "cost Cuban importers up to 30 percent more ... over World Scale rate." p. 13.

19. Richard Garfield and Sarah Santana, op. cit. See also Cuba Update, Winter 1997, p. 32.

20. Universal Declaration of Human Rights, December 10, 1948.

21. Julia Sweig and Kai Bird, op. cit. See too Peter Schwab, "Views On Cuba: Life is Improving," The Miami Herald, May 2, 1997, p. 21A. For additional and iconoclastic views of Miguel Barnet, who apparently carves out time to meet foreign authors, see Tom Miller, Trading with the Enemy: A Yankee Travels Through Castro's Cuba (New York: Basic Books, 1996).

Peter Schwab is Professor of Political Science at Purchase College, the State University of New York. He is the author with Adamantia Pollis of Human Rights: Cultural and Ideological Perspectives (Praeger Publishers, 1980), and Ethiopia: Politics, Economics and Society (London: Frances Pinter, 1985). The author would like to thank those Cuban professionals who granted him time to pose questions and obtain information.

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