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BMJ No 7120 Volume 315 Editorial Saturday 29 November 1997 Embargoes that endanger health Doctors should oppose them See Personal view p 1474, Letter p 1463 If all else fails you can starve your enemy out. Or let disease, unchecked, take its toll. A personal view (p 1474)(1) and a letter (p 1463)(2) in this week's journal remind us that the barbarous tactics of earlier wars still have their uses. Both articles deal with the effects on health of rigorously enforced embargoes. The personal view from three visitors to Iraq augments the account we published a year ago on the effects of sanctions on surgical practice.(3) Barnouti wrote then that they had "led to the disruption and collapse of the basic medical system, revealing the inhuman face of sanctions of such severity and length." Should they continue "the already awful situation of medical services could become even worse." On the basis of visits to a wide range of Iraqi hospitals and health centres, the authors of this week's personal view found that problems with spare parts and maintenance had put half the diagnostic and therapeutic equipment out of action. Antibiotics, antiasthmatic drugs, and analgesics stronger than aspirin were in short supply, with predictable results. They found a population "burdened by a rapid rise in serious infectious diseases, nutritional deficiencies among pregnant women and young children, and other treatable conditions for which neither the right drugs nor operations are available." This sentence can be found almost verbatim in the summary of a report from the American Association for World Health (which serves as the US committee for the World Health Organisation and the Pan American Health Organisation) - except that this time the country is Cuba.(4) This reports the effects on health of the financial noose that America has been tightening around the neck of its diminutive neighbour since 1960.(4) Expert medical opinion was that "the US embargo has caused a significant rise in suffering - and even deaths - in Cuba." Although America has embargoed all trade with Cuba since 1961, the effects were limited so long as the Eastern bloc supported Cuba. With the collapse of this formation in 1989 came a sudden end to $4-6 billion in subsidised and bartered trade. The US Congress then passed the 1992 Cuban Democracy Act, which prohibited trade between foreign subsidiaries of American companies and Cuba. As some 90% of this trade was in food and medicines, the number of unmet medical needs has "sharply accelerated." An epidemic of 50,000 cases of optic and peripheral neuropathy occurred in Cuba between 1991 and 1993, which an official report attributed "to reduced nutrient intake caused by the country's deteriorating economic situation and the high prevalence of tobacco use."(5) Licences to sell medicines and medical equipment can be applied for, but the red tape is so daunting that only four companies obtained such licences from October 1992 to May 1995. The report notes that "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 medicine to ordinary citizens. Such an embargo appears to violate the most basic international charters and conventions governing human rights, including ... the articles of the Geneva Convention governing the treatment of civilians during wartime."(4) And Cuba isn't even at war with the United States. But a war of sorts is raging, as Leon Eisenberg has recently argued in the New England Journal of Medicine. "The Cuban and Iraqi instances make it abundantly clear that economic sanctions are, at their core, a war against public health. Our professional ethic demands the defense of public health Thus, as physicians, we have a moral imperative to call for the end of sanctions."(6) Neither individually nor collectively can doctors let themselves off the hook, however messy the issues. They are obliged to use their skills to improve and protect people's health, wherever they are. Doctors should therefore oppose economic embargoes, sanctions, and blockades wherever these are likely to endanger health. Last month the governing council of the American Public Health Association urged that essential humanitarian goods should be exempted from embargoes and that the health and wellbeing of embargoed populations should be aggressively monitored. As well as individual action, doctors can apply pressure on governments through their professional organisations. International bodies could pack the greatest punch of all: if ever an issue deserved to be taken up by the World Health Organisation and the World Medical Association then this is one. Tony Delamothe Deputy editor, BMJ email: tdelamothe@bmj.com References 1 Garfield R, Zaidi S, Lennock J. Medical care in Iraq after six years of sanctions. BMJ 1997;315:1474-5. 2 Parnham-Cope D. Doctors have moral imperative to call for end to embargo on Cuba. BMJ 1997;315:1463. 3 Barnouti H N. Effect of sanctions on surgical practice. BMJ 1996:313:1474-5. 4 Denial of food and medicine: the impact of the US embargo on health and nutrition in Cuba. Washington: American Association for World Health, 1997. 5 Cuba Neuropathy Field Investigation Team. Epidemic optic neuropathy in Cuba-clinial characterization and risk factors. N Engl J Med 1996;333:1176-82. 6 Eisenberg L. The sleep of reason produces monsters: human costs of economic sanctions. N Engl J Med 1997;336:1248-50. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline