The impact of the economic crisis and the US embargo on health in Cuba

Interplay between sanctions, donor conditionality, and food insecurity in complex emergencies: the case of Syria

Thirteen years into conflict, Syria remains one of the world's major humanitarian crises. Food insecurity has reached unprecedented levels in the country, with millions of civilians facing starvation and hunger. The key drivers of this are conflict-related, nature-induced, and, importantly, man-made policies. Semi-comprehensive sanctions against the country and donor conditionality vis-à-vis humanitarian operators' work are prime examples of the latter. These policies are inextricably linked with food insecurity in Syria and have direct and indirect impacts on it. Understanding the ongoing crisis as a complex emergency, this paper examines the interplay between sanctions, donor conditionality, and food insecurity, an understudied subject in the Syrian context. It explores how sanctions and donor conditionality influence three key dimensions of food security, namely, availability, affordability and economic access, and utilisation, and subsequently worsen the conditions confronting the Syrian population. The paper contributes to discussions on food security in conflict settings and how sanctions negatively affect civilians in targeted countries.

Direct and indirect effects of economic sanctions on health: a systematic narrative literature review

BACKGROUND

Economic sanctions are defined as restrictions imposed by other countries against individuals, groups, or governments of other countries. These sanctions have a detrimental impact on the economies of countries and can also limit access to healthcare services for people as a secondary consequence. This study aims to systematically review the literature to examine the direct and indirect effects of economic sanctions on health through a narrative synthesis.

METHODS

This systematic literature review was limited to papers published between January 1990 and July 2023. Relevant documents published in English and Persian were searched for in databases including Cochrane Library, PubMed, Embase, Scopus, Web of Science, SID, Magiran, and Irandoc. The direct and indirect effects of sanctions on health were classified using two frameworks proposed by the World Health Organization (WHO): the Health System Building Blocks and "Social Determinants of Health".

RESULTS

Out of a total of 18,219 articles, 59 were selected based on inclusion criteria. The effects of sanctions were divided into direct and indirect groups. Direct effects encompassed seven main themes: access to essential medicine, medical products, vaccines and technologies; financing; health workforce; service delivery; research and health information systems; health outcomes; and financial risk protection. Indirect effects also were classified into six main themes: socioeconomic status; food and agricultural products; stress; early life conditions; high-risk behaviors and addiction; and transport. Most studies focused on the access to medicines, food, economic and social status.

CONCLUSIONS

Economic sanctions have had profoundly negative impacts on all aspects of the healthcare system. The international community must address these effects on health and take necessary measures to prevent or mitigate them, particularly in ensuring the provision of basic and essential healthcare needs for individuals and communities.

The impact of international sanctions on food security and Sustainable Development Goal 2 (SDG-2)

OBJECTIVES

Food security plays a critical role in achieving Sustainable Development Goal 2 (SDG-2) and public health outcomes; however, its effectiveness under the impact of international sanctions remains unclear. This study examined the impact of international sanctions on achieving SDG-2 and food security.

STUDY DESIGN

This cross-country empirical analysis was based on a combined database that included data from the Global Sanctions Data Base (GSDB), Food and Agriculture Organization Statistics (FAOSTAT) and United Nations (UN) Comtrade.

METHODS

First, an instrumental variable (IV) strategy was used to deal with the endogeneity of other events in target countries' sanctions. Second, a two-stage least square (2SLS) regression was conducted using high-dimensional fixed effects. Third, based on the Structural Gravity Model, a Poisson pseudo maximum likelihood (PPML) regression on bilateral agricultural trade was performed.

RESULTS

Findings from this study showed that international sanctions had a negative impact on the achievement of SDG-2 and food security, which was associated with poor public health outcomes. This was mainly evidenced by an increase in the prevalence of undernourishment and a high population of children with moderate or severe stunting. Sanctions were also shown to distort the agricultural value-added share and decrease domestic agricultural production. In addition, sanctions impeded bilateral import supply, which resulted in a lower import value and quantity, and a higher import price.

CONCLUSIONS

Food security and agricultural sustainability associated with hunger, nutrition and health from 1950 to 2019 were significantly associated with international sanctions. Under the uncertain shock of international sanctions, progress towards SDG-2 deteriorated, mainly for Targets 2.1, 2.2 and 2.a, and the impact was non uniform across all targets. From a sociopolitical perspective, the empirical findings of this study provide vital lessons for policymakers and public health communities to increase humanitarian outreach.

Economic sanctions and spread of infectious diseases

Economic sanctions can induce economic crises and compromise the determinants of health. In the literature, economic crises have been found to increase the risk of infectious disease outbreaks. Presumably, sanctions can increase the risk of infectious disease spreads, indirectly. However, non-economic factors can fuel the adverse impact of sanctions, including political consequences of sanctions and civil war. We performed a systematic literature review of articles in Embase, MEDLINE, Scopus, Web of Science, Cochrane Library, and the grey literature to assess empirically the impact of economic sanctions on the spread of infectious diseases within and beyond the borders of sanctioned countries. Our review did not identify any study meeting our inclusion criteria. Most of the studies did not control for major socio-political events, particularly armed conflicts in the sanctioned countries. This discovery underscores a notable gap in the examination of the impact of economic sanctions on the propagation of infectious diseases, presenting a threat to global health. Using the social-ecological model, we hypothesize how the economic crisis resulting from economic sanctions affects determinants of health, increases the risk of the spread of infectious diseases and hinders the response capacity of health systems.

The human cost of economic sanctions and strategies for building health system resilience: A scoping review of studies in Iran

OBJECTIVES

This review aimed to analyse the impacts of international economic sanctions on the overall health status of Iranians and the health system performance of Iran, in addition to identifying effective strategies for making the health system resilient to sanctions.

STUDY DESIGN

A scoping review.

METHODS

Three databases and grey literature were reviewed, and additional papers were identified in the lists of references. Two authors reviewed papers to check duplications and screen through inclusion/exclusion criteria. Furthermore, a narrative approach was employed to synthesise the findings.

RESULTS

Given overall health impacts, economic sanctions are believed to have adverse effects on Iranian's health and cause significant financial hardships in accessing healthcare services. These hardships mostly affect those in marginalised and vulnerable groups. Economic sanctions degrade Iran's health system by negatively impacting health services' availability. The detrimental effects of sanctions on economic and social circumstances were also documented. Economic sanctions could also adversely affect health research and education. Most strategies identified for health system resilience to sanctions are related to the health system governance.

CONCLUSIONS

Even if essential medicines and supplies are exempted from the sanction regime, the impact of economic sanctions on public health is unavoidable. The quantification of the effect economic sanctions on different health-related areas needs by further research. The measures identified for dealing with sanction can be considered in other countries but more work is needed to explore how health of people can be resilient against negative consequences of sanctions.

Responding to the Humanitarian Crisis in Gaza: Damned if You do… Damned if You don't!

Palestine, since 1948, has endured frequent military occupations and uprisings, intifadas, in a limited geographic area that has resulted in one of the worst humanitarian crises. The prolonged nature of this military occupation has created a biosphere of war that is uninhabitable, whereby Palestinians suffer from physical, psychological, and social wounds. Israel also imposed restrictive measures in Gaza, making it difficult for Palestinians to obtain permits to work and travel throughout Palestine. Israel continued to intensify the restrictions on Gaza, reaching a blockade on the Gaza Strip, which cut off Palestinians from Jerusalem, where hospitals, banks, and vital services are found. This form of permanent siege resulted in a surge in the unemployment rate, poverty, and poor nutritional and wellbeing status. The siege also resulted in the largest open-air prison, as people became stuck between an incomplete life and the absence of total death. The major challenge is that humanitarian interventions, in the case of Gaza, are ineffective, as they are part of the siege framework. This is because any humanitarian aid meant for Gaza needs to be approved by Israel. Thus, when the emergency becomes chronic and humanitarian interventions become part of the siege framework, how can Gaza rebuild its health capacity in a permanent emergency, and to what extent can the humanitarian sector make a change?

Economic Sanctions Affecting Household Food and Nutrition Security and Policies to Cope With Them: A Systematic Review

BACKGROUND

This review was conducted to identify the impact of economic sanctions on household food and nutrition security and policies to cope with them in countries exposed to sanctions.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 2020 were used to identify, select, appraise, and synthesize studies. Electronic databases in addition to Persian ones have been systematically searched for all related documents published until March 2022. Exclusion criteria were: lack of data related to food insecurity in countries subject to sanction and very low quality of the article. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal checklists. The results were presented as qualitative and quantitative syntheses.

RESULTS

Of 1428 identified studies, 36 publications remained in the review, which belong to Iran (n=8), Cuba (n=8), Russia (n=7), Iraq (n=7), and Haiti (n=6), respectively. Declining gross domestic product (GDP), devaluation of the national currency, and the quality of food, increase in inflation, unemployment, and consumer prices, infant and under 5 years mortality, energy, and protein deficiency, and the poverty rate were reported as sanction consequences. The most important strategies to improve food security were the humanitarian assistance provided by the international community (Haiti), equity and priority for vulnerable groups mainly by expanding the healthcare system (Cuba), adopting a food ration system in the oil-for-food program, and fixing the price of food baskets (Iraq), import substitution and self-sufficiency (Russia), support domestic production, direct and indirect support and compensation packages for vulnerable households (the approach of resistance economy in Iran).

CONCLUSION

Due to the heterogeneity of studies, meta-analysis was not possible. Since inadequate physical and economic food access caused by sanctions affects especially disadvantaged and vulnerable groups, planning to improve food security and providing support packages for these groups seems necessary.

The impact of economic sanctions on health and health systems in low-income and middle-income countries: a systematic review and narrative synthesis

INTRODUCTION

Economic sanctions restrict customary commercial and financial ties between states to induce change in political constitution or conduct of the targeted country. Although the stated goals of sanctions often include humanitarian objectives, prospective procedures for health risk assessment are not regularly incorporated in their implementation. Moreover, past experience suggests that the burden of economic isolation may fall on the civilian population. We present key findings from a WHO-sponsored evidence review on the impact of economic sanctions on health and health systems in low-income and middle-income countries, aiming at comprehensive coverage and explicit consideration of issues of causality and mechanisms.

METHODS

Broad searches of PubMed and Google Scholar (1970-2021) were designed to retrieve published and grey English-language literature expected to cut across disciplines, terminology and research methods. Studies providing an impact estimate were rated by a structured assessment based on ROBINS-I risk of bias domains, synthesised via vote counting and contextualised into the broader literature through a thematic synthesis.

RESULTS

Included studies (185) were mostly peer-reviewed, mostly single-country, largely coming from medicine and public health, and chiefly concerned with three important target countries-Iraq, Haiti and Iran. Among studies providing impact estimates (31), most raised multiple risk-of-bias concerns. Excluding those with data integrity issues, a significant proportion (21/27) reported consistently adverse effects of sanctions across examined outcomes, with no apparent association to assessed quality, focus on early episodes or publication period. The thematic synthesis highlights the complexity of sanctions, their multidimensionality and the possible mechanisms of impact.

CONCLUSION

Future research should draw on qualitative knowledge to collect domain-relevant data, combining it with better estimation techniques and study design. However, only the adoption of a risk assessment framework based on prospective data collection and monitoring can certify claims that civilians are adequately protected.

Health system to response to economic sanctions: global evidence and lesson learned from Iran

BACKGROUND

Sanctions have direct and indirect impacts on people's lives. Therefore, the health systems of countries targeted by sanctions must respond effectively. This study proposes a set of mitigating measures and response strategies to improve the health systems of countries under sanctions.

METHODS

This three-stage study was conducted in Iran within the 2020-2021 period, in which a rapid review of evidence was carried out to identify the measures implemented or proposed to make the health system resilient in confronting sanctions. A qualitative approach was then adopted to determine how the health system could be improved to response to sanctions from the perspectives of 10 key experts. Semi-structured interviews and document analysis were conducted for data collection. Finally, a two-round Delphi technique was employed to help eleven experts reach a consensus on a set of mitigating measures, which were then prioritized.

RESULTS

In this research, 62 proposed or implemented mitigating measures were extracted from 13 eligible studies to improve the health system performance in confronting sanctions. Moreover, 18 measures were identified in interviews for a better health system response to sanctions. They were then classified as five categories: sustained financing, good governance, integrated and updated health information systems, qualified workforce, and efficient and equitable service delivery. In the first Delphi round, 28 mitigating measures were discovered. Nine measures were identified as more effective and feasible in both short and long runs. They were introduced as below: conducting proactive inventory control, developing the nationally essential list of medicines, providing additional clarification that oil revenues can be freely used for medicines procurement, defining tailored health service packages for vulnerable populations, establishing and enhancing an efficient surveillance system, reducing prices of imported medicines, developing dual policies of equity and priority for vulnerable groups, institutionalizing fair and effective resource allocations, and providing clinical guidelines.

CONCLUSIONS

According to the findings, the most critical areas for the resilience of a health system in confronting sanctions include strengthening particular components of governance, improving efficiency, and caring for vulnerable populations. The experts collectively emphasized investment in domestic capacities, public participation, and health diplomacy. Despite the proposed measures, it is unclear how effective these are and, especially whether they can significantly affect the harsh impacts of sanctions on health. Moreover, intensive and long-term sanctions have significant irreversible outcomes that cannot be reversed easily or quickly.

An American Perspective of the Dental and Public Health Initiatives in Cuba

Aim:

To compare following the Cuban Revolution, Cuba’s economy and civil society was transformed by the initiation of a program of nationalization and political consolidation. The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the healthcare of its citizens. Other industrialized nations continue to surpass the US in health-related outcomes indicating areas of improvement in its healthcare system. Assessing the successes and failures as well as the advantages and disadvantages of other countries’ healthcare systems may be instrumental in the development of modifications to the organization and delivery system of healthcare in the US. This paper aims to report the information attained from previous literature as well as from first-hand observations from a public health trip to Cuba in order to compare the healthcare systems in Cuba and the United States.

Materials and Methods:

A group of New York University College of Dentistry faculty and students traveled to Cuba in April 2019 for professional research and professional meetings (CFR 515.564). While in Cuba, the researchers took written notes of the lecture-based material and conversations. Upon return to the United States, published literature was searched for the collection of any additional data and all qualitative data and quantitative data was compiled and organized. Since 1959, Cuba has made continuous adjustments and improvements to its universal, free and accessible healthcare system.

Results:

There have been notable improvements to the country’s public health status, such as the implementation of an immunization program and subsequent eradication of communicable diseases, such as polio and rubella. Additionally, the implementation of the National Program on Dentistry guarantees dental care to all Cuban children under the age of 19. Today, the Cuban National Health System (NHS) initiatives have evolved to combat the novel coronavirus (COVID-19) pandemic.

Conclusion:

Recognizing the advantages as well as the disadvantages of the Cuba’s National Health System (NHS) would be useful for future policymakers in the United States. Cuban approaches to health could be tailored to the United States environment to improve healthcare effectiveness and population health status in the future.

The Effect of COVID-19 on the Hospitality Industry: The Implication for Open Innovation

The current coronavirus pandemic (COVID-19) has led the world toward severe socio-economic crisis and psychological distress. It has severely hit the economy; but the service sector, particularly the hospitality industry, is hard hit by it. It increases the sense of insecurity among the employees and their perception of being unemployed, adversely affecting their mental health. This research aims to contribute to the emerging debate by investigating the effect of economic crisis and non-employability on employees’ mental health through perceived job insecurity under the pandemic situation. It empirically examines the underlying framework by surveying 372 employees of the hospitality industry during COVID-19. Results indicate that perceived job insecurity mediates the relationship of fear of economic crisis, non-employability, and mental health. Furthermore, the contingency of fear of COVID-19 strengthens the indirect relationship of fear of economic crisis on mental health through perceived job insecurity. The findings will provide a new dimension to the managers to deal with the psychological factors associated with the employees’ mental health and add to the emerging literature of behavioral sciences. The study also highlights the increasing need for investment in the digital infrastructure and smart technologies for the hospitality industry.

The potential impact of the COVID-19 response related lockdown on TB incidence and mortality in India

India has the highest burden of incident tuberculosis (TB) cases and deaths globally. TB is strongly associated with poverty and this risk is largely mediated by undernutrition in India. COVID-19 response related lockdown has resulted in an economic crisis which may double levels of poverty, has exacerbated food insecurity, and disrupted TB services. These developments may have serious implications for TB progression and transmission in India. The nutritional status of a population is a strong determinant of the TB incidence, and undernutrition in adults alone accounts for 32-44% of TB incidence in India. A systematic review has shown that a 14% increase in TB incidence can occur per one unit decrease in body mass index (BMI), across the BMI range of 18.5-30 kg/m2. We believe that one unit decrease in BMI (corresponding to a 2-3 kg weight loss) may result in the poor in India as a result of the lockdown and its aftermath. This may result in an increase in estimated (uncertainty interval) incident TB by 185 610 (180 230, 190 990) cases. A 59% reduction in TB case detection between end March and May 2020, may result in an estimated (uncertainty interval) additional 87 711 (59 998, 120 630) TB deaths [19.5% increase (14.5, 24.7)] in 2020. Disadvantaged social groups and those living in states with higher levels of poverty, under-nutrition,and migrant workers are at particular risk. We suggest enhanced rations including pulses through the public distribution system and direct cash transfers to the poor pending restoration of livelihoods. TB services should be resumed immediately with enhanced efforts at case detection including active case finding. To prevent deaths among TB detected within the national TB programme, systemic identification, referral and management of severe disease at notification should be considered.

Provision of Peace and Right to Health through Sanctions: Threats and Opportunities

According to the purposes for the formation of the United Nations, sophistication of institutions like the Security Council must be evaluated based on the provision of peace and how they guarantee human rights. Therefore, in case Security Council does not follow these two mentioned factors, its function would be itself a threat to the international peace and security. This analytical research is based on collecting library theoretical data related to different field studies which investigated the effects of sanctions issued by the Security Council, the United States and the European Union on citizens' health and tried to assess both their efficiency and legitimacy. The right to health is connected with the right of living. In case enough drugs, appropriate treatment and medical equipment are not provided at the proper time, both physical and mental health might be threatened and this can cause death of a large number of people. Considering the Security Council as an institution which is expected to take into account the citizens' basic rights and not to ignore its own initial objective, the present paper was an attempt to provide explanations for the above concepts and their relationships and to analyze the findings of previous field studies. The paper concluded that sanctions issued by the Security Council and the United States are potentially functioning as threats to the international peace and so these sanctions are violating the citizens' right to health.

Economic sanctions and HIV/AIDS in women

HIV/AIDS has disproportionately affected women worldwide. Several studies focus on economic sanctions and the health of populations, but little attention has been paid to the effects of sanctions on HIV rates. This study examines the influence of economic sanctions on HIV in women and finds that sanctions increase women's HIV rate by decreasing female labor participation. These findings are in line with previous findings that sanctions negatively affect public health in general as well as women in particular. All these findings suggest that policy makers need to consider more carefully the scourge of HIV/AIDS among women when formulating their policies toward target countries.

Cuba's Strategy Toward Universal Health

After 40 years of the Alma Ata Declaration on primary health care, the Pan American Journal of Public Health published an actualized overview of Cuban policies on health and well-being. It describes the longstanding and successful experience of this socialist country, developed in adverse and complex circumstances. The Cuban case remains one of the leading examples of a comprehensive governmental approach toward population health and well-being. The analysis underscores the essential role of continued political will toward population health.

Cuban Epidemic Optic Neuropathy (1991-1993) and José Saramago's Novel Blindness (1995)

PURPOSE

This article reviews the history of Cuban epidemic optic neuropathy (1991-1993), which caused visual loss, peripheral neuralgias, and other neurologic symptoms in over 50,000 persons, an incidence of almost 0.5% of the entire population. The clinical findings, etiology, and treatment are described. We then relate the Cuban epidemic to the fictional epidemic of contagious blindness depicted by Nobel Laureate José Saramago in his 1995 novel Blindness. This novel describes an unnamed modern city in which all inhabitants, except the ophthalmologist's wife, are affected with a white, not black, blindness.

DESIGN

Historical review and literary essay.

METHODS

The sources for the Cuban epidemic were an extensive review of the published literature and personal communications with physicians who treated these patients. Both authors have analyzed the novel and the critical literature about Saramago's writings.

RESULTS

Though Saramago uses the epidemic of blindness as an allegory to comment on human weakness and immorality, he may also have known of the actual Cuban epidemic. Saramago was a lifelong member of the Communist party, as well as a friend of Fidel Castro and admirer of the Cuban government. We have no proof that Blindness was influenced by the Cuban epidemic, but we find it plausible.

CONCLUSION

It is valuable to examine the real and fictional epidemics side by side, not least because Saramago's novel depicts the actions of an ophthalmologist during an epidemic of blindness. Ophthalmologists may be interested in a novel that uses the language of eyes, vision, sight, and blindness extensively.

Assessment of the Effects of Economic Sanctions on Iranians' Right to Health by Using Human Rights Impact Assessment Tool: A Systematic Review

BACKGROUND

Over the years, economic sanctions have contributed to violation of right to health in target countries. Iran has been under comprehensive unilateral economic sanctions by groups of countries (not United Nations [UN]) in recent years. They have been intensified from 2012 because of international community's uncertainty about peaceful purpose of Iran's nuclear program and inadequacy of trust-building actions of this country. This review aimed to identify the humanitarian effects of the sanctions on the right of Iranians to health and the obligations of Iran and international community about it.

METHODS

To assess economic sanction policies and identify violated rights and the obligations of states according to international human rights laws, in this study, Human Rights Impact Assessments (HRIA) tool is used. Applying this tool requires collection of evidences regarding the situation of rights. To provide such evidence, a systematic review of literature which involved 55 papers retrieved from the web-based databases and official webpages of Iran's government and UN' health and human rights committees and organizations was done. All articles about the consequences of economic sanctions related to nuclear activities of Iran on welfare and health of Iranians published from January 2012 till February 2017 in English and Persian languages were included. Search terms were economic sanctions, embargoes, Iran, welfare, health and medicine. Additional studies were identified by cross checking the reference lists of accessed articles. All selected papers were abstracted and entered into a matrix describing study design and findings, and categorized into a framework of themes reflecting the areas covered (health and its determinants). According to HRIA framework, related obligations of Iran and other states about adverse effects of the sanctions on Iranians' right to health were extracted.

RESULTS

The sanctions on Iran caused a fall of country's revenues, devaluation of national currency, and increase of inflation and unemployment. These all resulted in deterioration of people's overall welfare and lowering their ability to access the necessities of a standard life such as nutritious food, healthcare and medicine. Also, the sanctions on banking, financial system and shipment led to scarcity of quality lifesaving medicines. The impacts of sanctions were more immense on the lives of the poor, patients, women and children. Humanitarian exemptions did not protect Iranians from the adverse effects of sanctions.

CONCLUSION

Countries which imposed economic sanctions against Iran have violated Iranians' right to health. International community should have predicted any probable humanitarian effects of sanctions and used any necessary means to prevent it. Furthermore, Iran should have used any essential means to protect people from the adverse effects of sanctions. Now, they should work on alleviation of the negative effects of sanctions. Even though, some of the effects such as disability and death cannot be compensated. In future, before imposition of sanctions, decisions makers should advice an international order to prevent such impacts on targeted countries' populations.

Not just salsa and cigars: mental health care in Cuba

Given the marginal nature of psychiatry in terms of Western health priorities, it is always worth reviewing how countries with clearly different political systems treat their mentally ill. The 40-year economic embargo imposed by the USA on Cuba, the effects of which have been compounded by the hardships suffered during the ‘Special Period’ from 1989 onwards when the collapse of the Soviet Union left the island's economy in ruins (Pilling, 2001), is one of the most stringent of its kind. It prohibits the sale of food, and sharply restricts the sale of medicines and medical equipment, which, given the USA's pre-eminence in the pharmaceutical industry, effectively bars Cuba from purchasing nearly half of the new world class drugs on the market (Rojas Ochoa, 1997). Between 1989 and 1993, Cuba's gross domestic product fell by 35% and exports declined by 75% (Pan American Health Organisation, 1999). This has reduced the availability of resources and has adversely affected some health determinants and certain aspects of the population's health status. Despite this, however, Cuba has developed a system prioritised to primary and preventive care, with an infant mortality rate half that of the city of Washington, DC (World Health Organization & Pan American Health Organization, 1997; Casas et al, 2001). Furthermore, biotechnology and family medicine are being developed by Cuba as a human resource for other developing countries. Cuban medical schools also train physicians specifically for many developing countries around the world (Waitzkin et al, 1997).

Trade in medicines and the public's health: a time series analysis of import disruptions during the 2015 India-Nepal border blockade

BACKGROUND

Nepal was struck by devastating earthquakes in April-May 2015, followed by the India-Nepal border blockade later that year.

METHODS

We used the United Nations Commodity Trade Statistics (UN Comtrade) database to analyse exports of various health commodities from India to Nepal from January 2011-September 2016. We used time-series regressions of trading volume vs. unit price to ask how well Nepal's trading history with India prior to the earthquake and blockade was able to predict unit prices of health commodities imported into Nepal during and after the earthquake and the blockade. Regression residuals were used to quantify the extent to which the blockade impacted the price of healthcare commodities crossing into Nepal.

RESULTS

During the blockade period (September 2015-early February 2016), the volume of all retail medicines traded across the India-Nepal border was reduced by 46.5% compared to same months in 2014-2015. For medical dressings, large volumes were exported from India to Nepal during and shortly after the earthquakes (May-June 2015), but decreased soon thereafter. During the earthquake, the difference between observed and predicted values of unit price (residuals) for all commodities show no statistical outliers. However, during the border blockade, Nepal paid USD 22.3 million more for retail medicines than one would have predicted based on its prior trading history with India, enough to provide healthcare to nearly half of Kathmandu's citizens for 1 year.

CONCLUSION

The India-Nepal blockade was a geopolitical natural experiment demonstrating how a land-locked country is vulnerable to the vagaries of its primary trading partner. Although short-lived, the blockade had an immediate impact on traded medicine volumes and prices, and provided a large opportunity cost with implications for public health.

Gender disparities in mortality from infectious diseases in Serbia, 1991-2014: a time of civil wars and global crisis

Infectious diseases remain one of the leading causes of death worldwide. The aim of this descriptive epidemiological study was to analyse the trends in mortality from infectious diseases in Serbia (excluding the Autonomous Province of Kosovo & Metohia) from 1991 to 2014 using joinpoint regression analysis. The mortality rates from infectious diseases were found to have increased markedly from 1991 to 1994 (+12·4% per year), followed by a significant decline from 1994 to 2009 (-4·6% per year) and then another increase from 2009 to 2014 (+4·3% per year). Throughout the study period, mortality rates were consistently higher in men than in women. Although a substantial decline was observed for young people of both sexes, no consistent pattern was evident for the middle-aged nor the elderly. Since 1991, septicaemia has emerged as a leading cause of infectious disease mortality, particularly in older men. The Yugoslav civil wars in the 1990s and the global financial crisis in 2008 corresponded with changes in the trends in mortality from infectious diseases in Serbia, with the elderly showing particular vulnerability during those time periods. Data presented in this study might be useful to improve control of infectious diseases in Serbia.

The Impact of Cuban Economic Reform on Older Persons

This paper discusses the economic reforms initiated by Cuban President Raúl Castro in 2008 and its effect on the country's fast-growing, vulnerable population of older persons 60+ years of age. Cubans are living longer and the country has a very low birthrate. These two factors combined have reduced the proportion of the population in the work force. This adversely affects the economy. Population aging is a major reason why the government has introduced structural reforms and reduced social spending, which have weakened the welfare state on which older persons depend. Many older persons have become critical of the reforms over time. Policy makers need to address the impact the reforms are having on older Cubans and consider them as active participants in economic reform. Data for this paper come from qualitative, case study research carried out in Havana between the years 2008-15 and from a review of the literature on aging and economic reforms in Cuba. Two case studies illustrate the impact of the economic reforms on older persons.

Eating Behaviors in Cuban Adults: Results from an Exploratory Transcultural Study

This study aims to investigate eating behaviors in Cuban adults and compare them with those of a developed Western country, Italy. The study also aimed to determine the overall accuracy of a predictive model intended to define variables which could be used to discriminate between nationalities. Participants were 283 normal weight individuals from Cuba (n = 158) and Italy (n = 125). Italians had higher scores for restrained eating on the questionnaire than Cubans with a considerable effect size. This trend was also found for emotional eating and binge eating, as well as number of current dieters, despite the fact that effect sizes were small. On the other hand, Cubans, when compared to Italians reported higher scores for food thought suppression with reward responsiveness and restrained eating emerging as significant predictors of between-country differences. To conclude, eating behaviors in Cubans could be different from those reported in European countries, perhaps as a consequence of Cuba's recent history.

The health effects of the global financial crisis: can we reconcile the differing views? A network analysis of literature across disciplines

Why are researchers studying the health effects of economic change reaching markedly varying conclusions? To understand these differences, we first systematically searched Web of Science for the literature on recessions and health yielding 461 articles and 14,401 cited documents. We then undertook a network analysis of co-citation pattern by disciplines, journals and backgrounds of the authors, followed by a chronological review of the literature, to trace the evolution of ideas. We then examined the extent to which earlier literature predicted what has happened in the 2007-2012 crisis. Our analysis finds the literature is dominated by disciplinary silos, with economics studies predominantly citing each other and relative isolation of psychiatry and substance abuse journals. Different philosophical approaches to assessing causality appear to contribute to varying interpretations, a tendency that is unlikely to be resolved without a shift in research norms. We conclude by calling for more inter-disciplinary research that combines empirical findings with a search for plausible mechanisms. This approach would evaluate not only the effects of economic shocks but also the mechanisms that offer protection against them.

A Time for Action on Health Inequities: Foundations of the 2014 Geneva Declaration on Person- and People-centered Integrated Health Care for All

Global inequalities contribute to marked disparities in health and wellness of human populations. Many opportunities now exist to provide health care to all people in a person- and people-centered way that is effective, equitable, and sustainable. We review these opportunities and the scientific, historical, and philosophical considerations that form the basis for the International College of Person-centered Medicine's 2014 Geneva Declaration on Person- and People-centered Integrated Health Care for All. Using consistent time-series data, we critically examine examples of universal healthcare systems in Chile, Spain, and Cuba. In a person-centered approach to public health, people are recognized to have intrinsic dignity and are treated with respect to encourage their developing health and happiness. A person-centered approach supports the freedom and the responsibility to develop one's life in ways that are personally meaningful and that are respectful of others and the environment in which we live together. Evidence suggests that health care organizations function well when they operate in a person-and people-centered way because that stimulates better coordination, cooperation, and social trust. Health care coverage must be integrated at several interconnected levels in order to be effective, efficient, and fair. To reduce the burden of disease, integration is needed between the people seeking and delivering care, within the social network of each person, across the trajectory of each person's life, among primary caregivers and specialists, and across multiple sectors of society. For integration to succeed across all these levels, it must foster common values and a shared vision of the future.

Childhood atopic diseases and early life circumstances: an ecological study in Cuba

Background

Children are especially vulnerable during periods of resource shortage such as economic embargoes. They are likely to suffer most from poor nutrition, infectious diseases, and other ensuing short-term threats. Moreover, early life circumstances can have important consequences for long-term health. We examined the relationship between early childhood exposure to the Cuban economic situation in the nineties and the occurrence of atopic diseases later in childhood.

Methodology/Principal Findings

A cross-sectional study of 1321 primary schoolchildren aged 4–14 was conducted in two Cuban municipalities. Asthma, allergic rhinoconjunctivitis and atopic dermatitis were diagnosed using the International Study of Asthma and Allergies in Childhood questionnaire. Children were divided into three groups of exposure to the economic situation in the nineties according to birth date: (1) unexposed; (2) exposed during infancy; (3) exposed during infancy and early childhood. Associations were assessed using multiple logistic regression models. Exposure during infancy had a significant inverse association with the occurrence of asthma (OR 0.56, 95%CI 0.33–0.94) and allergic rhinoconjunctivitis (OR 0.46, 95%CI 0.25–0.85). The associations were stronger after longer exposure, i.e. during infancy and early childhood, for asthma (OR 0.40, 95% CI 0.17–0.95) and allergic rhinoconjunctivitis (OR 0.29, 95%CI 0.11–0.77). No significant associations were found for atopic dermatitis.

Conclusions/Significance

Exposure to the economic situation in the nineties during infancy and early childhood was inversely associated with asthma and allergic rhinoconjunctivitis occurrence later in childhood. We hypothesize that factors related to this period, such as infectious diseases and undernutrition, may have an attenuating effect on atopic disease development. The exact cause and underlying mechanisms need to be further elucidated.

Access to antiepileptic drug therapy in children in Camagüey Province, Cuba

Objective

To describe access to antiepileptic drug therapy and estimate the prevalence of epilepsy in children in Camagüey Province, Cuba.

Methods

All the community pharmacies in the province were visited and information collected about the number of children receiving antiepileptic drugs in 2009. Availability and cost of each antiepileptic drug were determined. The prevalence of epilepsy was estimated by determining the number of children receiving antiepileptic drugs.

Results

There were 923 children who received a total of 977 antiepileptic drugs in Camagüey Province. The estimated prevalence of epilepsy was 5.18 per thousand children which is lower than previously reported rates in other low and lower-middle income countries. Most of the children (871, 94%) received a single antiepileptic drug. Carbamazepine and valproate were the two most frequently prescribed antiepileptic drugs. Antiepileptic drugs were available from the local pharmacy on 76% of occasions. If the antiepileptic drug was not available from the local pharmacy, the parent had to travel to another pharmacy to obtain the medicine.

Conclusions

The estimated prevalence of epilepsy in children in Cuba is lower than that estimated in other lower-middle income countries. Access to drug therapy in children with epilepsy can be achieved in lower-middle income countries.

Public health services, an essential determinant of health during crisis. Lessons from Cuba, 1989-2000

During the 1990s, Cuba was able to overcome a severe crisis, almost without negative health impacts. This national retrospective study covering the years 1989-2000 analyses the country's strategy through essential social, demographic, health process and health outcome indicators. Gross domestic product (GDP) diminished by 34.76% between 1989 and 1993. In 1994 slow recuperation started. During the crisis, public health expenses increased. The number of family doctors rose from 9.22 to 27.03 per 104 inhabitants between 1989 and 2000. Infant mortality rate and life expectancy exemplify a series of health indicators that continued to improve during the crisis years, whereas low birth weight and tuberculosis incidence are among the few indicators that suffered deterioration. GDP is inversely related to tuberculosis incidence, whereas the average salary is inversely related to low birth weight. Infant mortality rate has a strong negative correlation with the health expenses per inhabitant, the number of maternal homes, the number of family doctors and the proportion of pregnant women receiving care in maternal homes. Life expectancy has a strong positive correlation with health expenses, the number of nursing personnel and the number of medical contacts per inhabitant. The Cuban strategy effectively resolved health risks during the crisis. In times of serious socio-economic constraints, a well conceptualized public health policy can play an important role in maintaining the overall well-being of a population.

The Cuban Experience in Public Health: Does Political Will Have a Role?

The role of political will in public health has been largely ignored. In Cuba, however, for the past 50 years, political will has been the ultimate, encompassing intersectoral action in public health. The excellent achievements in population health in Cuba during these 50 years have been widely recognized. Researchers have sought to explain this “Cuban paradox” by focusing on a large array of public health factors, including health promotion, primary care activities, and intersectoral action on health determinants. These factors constitute necessary but not sufficient conditions to achieve good health outcomes. This article defines political will and uses the experience of Cuba to illustrate the potential role of political will in public health. The authors suggest a framework for the evaluation of political will aimed at achieving good health, examining the “Five R's of political will,” five observable features that may provide systematic information on the direction and realization of political will: (1) renewal of commitment, (2) reform of the system, (3) resource development, (4) review of performance, and (5) responsible management. These five features focus the spotlight on the consistency between health goals and public discourse and action.

Prenatal exposure to wartime stress: long-term effect on coronary heart disease in later life

Background. Increased rates of coronary heart disease (CHD) and cerebrovascular disease in later life have been repeatedly observed in subjects with low birth-weight. One possible reason for low birth-weight is prenatal stress. Little is known about the influence of prenatal stress on lifelong health outcomes. Aims. In this study we investigate the influence of prenatal stress on CHD and cerebrovascular disease incidence in adult life. Methods. We analysed data originating from the Helsinki Birth Cohort Study including hospital data from all men and women born between 1934 and 1944 (n = 13,039) in two hospitals of Helsinki. We estimated the hazard function based on Weibull distribution. We compared those exposed and unexposed to bombings while in utero in terms of lifelong CHD and cerebrovascular disease hazard. Results. In women exposed to bombings while in utero, we observed higher survival rates of both CHD and cerebrovascular disease than in those unexposed. In men, the results were ambiguous. Conclusions. Our findings suggest that prenatal exposure to severe stress may be associated with protective effects on the development of CHD in later life.

Nutritional status, health conditions and socio-demographic factors in the elderly of Havana, Cuba: data from SABE survey

OBJECTIVE

To assess the association of nutritional status with sex, age, race/color, education, smoking, physical activity, hypertension, diabetes, and hospitalization in older adults residing in the city of Havana, Cuba.

METHODS

This was a cross-sectional, population-based household survey. A total of 1,905 persons (1,197 women and 708 men; ≥ 60 years) were examined between 1999 and 2000, selected by probabilistic sampling. Nutritional status was assessed by body mass index (BMI): BMI < 22.0 kg/m2 = underweight; BMI > 27.0 kg/m2 = overweight. Multinomial logistic regression analysis (crude and adjusted) was used.

RESULTS

The estimation of the prevalence of underweight was 33.0% and that of overweight was 29.6%. The adjusted regression model showed that the probability of underweight was higher in older age groups (OR = 1.63, 70-79 years; OR = 2.05, ≥ 80 years) and among smokers (OR = 1.83). There was negative association between underweight, and hypertension and diabetes. Hypertension (OR = 1.99) was positively associated with overweight. The lower likelihood of overweight was observed among men, smokers, and those aged 80 years and more.

CONCLUSION

The elderly population of Havana presents a vulnerable nutritional status in view of the prevalence of underweight and overweight. Increasing age, smoking, gender, and hypertension are the factors positively associated with vulnerable nutritional status.

The impact of economic recession on maternal and infant mortality: lessons from history

BACKGROUND

The effect of the recent world recession on population health has featured heavily in recent international meetings. Maternal health is a particular concern given that many countries were already falling short of their MDG targets for 2015.

METHODS

We utilise 20th century time series data from 14 high and middle income countries to investigate associations between previous economic recession and boom periods on maternal and infant outcomes (1936 to 2005). A first difference logarithmic model is used to investigate the association between short run fluctuations in GDP per capita (individual incomes) and changes in health outcomes. Separate models are estimated for four separate time periods.

RESULTS

The results suggest a modest but significant association between maternal and infant mortality and economic growth for early periods (1936 to 1965) but not more recent periods. Individual country data display markedly different patterns of response to economic changes. Japan and Canada were vulnerable to economic shocks in the post war period. In contrast, mortality rates in countries such as the UK and Italy and particularly the US appear little affected by economic fluctuations.

CONCLUSIONS

The data presented suggest that recessions do have a negative association with maternal and infant outcomes particularly in earlier stages of a country's development although the effects vary widely across different systems. Almost all of the 20 least wealthy countries have suffered a reduction of 10% or more in GDP per capita in at least one of the last five decades. The challenge for today's policy makers is the design and implementation of mechanisms that protect vulnerable populations from the effects of fluctuating national income.

Global health. Fifty years of U.S. embargo: Cuba's health outcomes and lessons

Despite sanctions’ impacts on medicine and medical supplies, Cuban health outcomes are comparable to those of developed countries.

Changes in occupational safety and health indices after the Korean economic crisis: analysis of a national sample, 1991-2007

We examined how the deregulation of South Korea's labor laws during the country's 1997 to 1998 economic crisis affected occupational safety and health. Although the economic index improved after the reforms, the total injury rate declined slowly and the incidence of occupational disease increased. The withdrawal of support for occupational safety and health is likely to have a sustained effect on public health.

The health implications of financial crisis: a review of the evidence

What will the current economic crisis mean for the health of the people of Northern Ireland? We review the experience of three major economic crises in the 20(th) century: the Great Depression (1929), the Post-communist Depression (early 1990 s) and the East Asian financial crisis (late 1990 s). Available evidence suggests that health is at risk in times of rapid economic change, in both booms and busts. However the impact on mortality is exacerbated where people have easy access to the means to harm themselves and is ameliorated by the presence of strong social cohesion and social protection systems. On this basis, Northern Ireland may escape relatively unscathed in the short term but as every crisis also provides an opportunity, this is an appropriate time for the Northern Ireland Executive to reflect on whether they are making a sufficient investment in the long term health of their population.

The effect of an international embargo on malnutrition and childhood mortality in rural Haiti

The study objective was to determine the effect of an international embargo against Haiti, from October 1991 through October 1994, on early childhood protein-energy malnutrition and all-cause mortality in a geographic area where humanitarian aid was continuously available to the children in the study. The authors used longitudinal anthropometric records on 1593 children, 24 months old or younger, living in the rural Grand Anse Department of Haiti from 1989 through 1996. Kaplan-Meier graphs for all-cause mortality accounting for malnutrition status and stratified by calendar period were applied to the database and assessed using logrank tests. Adjusted relative risks were assessed by Cox regression. The results show that despite the continuous availability of preventive services (1989-1996), higher all-cause mortality was more strongly associated with a calendar period coinciding with the international embargo than with periods before and after the embargo. The incidence of childhood mortality and of severe malnutrition were also higher during the period of the embargo than in the periods before and after the embargo. The findings suggest that future international sanctions, even those with humanitarian/medical exceptions, could result in substantial infant death.

Health in Cuba

The poorer countries of the world continue to struggle with an enormous health burden from diseases that we have long had the capacity to eliminate. Similarly, the health systems of some countries, rich and poor alike, are fragmented and inefficient, leaving many population groups underserved and often without health care access entirely. Cuba represents an important alternative example where modest infrastructure investments combined with a well-developed public health strategy have generated health status measures comparable with those of industrialized countries. Areas of success include control of infectious diseases, reduction in infant mortality, establishment of a research and biotechnology industry, and progress in control of chronic diseases, among others. If the Cuban experience were generalized to other poor and middle-income countries human health would be transformed. Given current political alignments, however, the major public health advances in Cuba, and the underlying strategy that has guided its health gains, have been systematically ignored. Scientists make claims to objectivity and empiricism that are often used to support an argument that they make unique contributions to social welfare. To justify those claims in the arena of international health, an open discussion should take place on the potential lessons to be learned from the Cuban experience.

Learning together: a Canada-Cuba research collaboration to improve the sustainable management of environmental health risks

OBJECTIVE

To build a national Cuban capacity for training environmental health professionals directly linked to the needs of policy-makers and communities.

PARTICIPANTS

The University of Manitoba and University of British Columbia collaborated with an established training centre in Cuba (the Instituto Nacional de Higiene y Epidemiologia--INHEM) and new centres in the Central (Santa Clara) and Eastern (Santiago) regions of the country.

SETTING

Cuba.

INTERVENTION

In the mid-1990s, a comprehensive curriculum (masters and diploma programs) was collaboratively developed, applying interactive teaching methods, and was delivered through a series of workshops and other interactions in Cuba, and short-term visits to Canada by Cuban PhD students.

OUTCOMES

The collaboration was successful in fulfilling capacity-building targets (over 50 Masters graduates, 467 Diploma graduates, over 30 trained core faculty in all regional centres as well as new curriculum and new accredited regional programs). Alongside this, a number of collaborative community-based research projects were undertaken in all three regions (drinking water in Santiago; housing and urban renewal, and dengue control in Havana; and tourism-related effects, and effective intersectoral management of population health determinants in Santa Clara).

CONCLUSION

The collaboration led to adopting new strategies for challenges such as a dengue epidemic in 2002, and new research on the effectiveness of intersectoral management of risks of particular interest to both Cuban and Canadian policy-makers. It triggered an ambitious collaboration between the Canadian-Cuban team and colleagues in Ecuador in order to build a similar national network there, built on South-South and North-South links.

Comparing environmental issues in Cuba before and after the Special Period: balancing sustainable development and survival

Following the Earth Summit in 1992, Cuba designed and implemented a variety of programs, administrative structures, and public awareness activities to promote sound environmental management and sustainable development. This came shortly after the fall of the Soviet Union and the strengthening of the US blockade in 1990, which resulted in a 35% drop in Cuban GDP. This period, referred to as the Special Period, witnessed a decrease in many environmentally damaging activities both by choice and by necessity, but also resulted in many decisions to resuscitate the Cuban economy. The purpose of this work was to compare and rank the environmental risks Cuba faced before and during the Special Period (1990-2000) using two Comparative environmental risk assessments (CERAs). To do so, an ecosystem integrity risk assessment matrix was constructed with 42 risk end points. The matrix assessed the risk posed by 17 problem areas including air pollution, water contamination, solid waste sites, pesticides and ecosystem degradation. The risks were calculated using five criteria: area affected, vulnerability of affected population, severity of impact, irreversibility of effect and uncertainty. To construct this matrix, both literature reviews and expert interviews in Cuba were conducted in 2000. The results showed a general decrease in risk scores during the Special Period. Before the Special Period, high risks were posed by: terrestrial degradation and industrial wastewater and sludge, followed by freshwater degradation, surface water stressors, and pesticides. After the Special Period, industrial wastewater and sludge and pesticides were no longer high-risk areas, but municipal wastewater and marine coastal degradation ranked higher than previously. Also, the risk endpoints most stressed after 1990 were affected by activities controlled by the government, such as mining and tourism, and lack of infrastructure. Therefore, the claims that public environmental education is the main pathway to sustainable development in Cuba seem uninformed and other management practices should be evaluated.

Economic crisis and access to care: Cuba's health care system since the collapse of the Soviet Union

This article explores the effects on access to health care in Cuba of the severe economic crisis that followed the collapse of the Soviet Union and the monetary and market reforms adopted to confront it. Economic crises undermine health and well-being. Widespread scarcities and self-seeking attitudes fostered by monetary and market relations could result in differential access to health services and resources, but the authors found no evidence of such differential access in Cuba. While Cubans generally complain about many shortages, including shortages of health services and resources before the economic recovery began in 1995, no interviewees reported systemic shortages or unequal access to health care services or resources; interviewees were particularly happy with their primary care services. These findings are consistent with official health care statistics, which show that, while secondary and tertiary care suffered in the early years of the crisis because of interruptions in access to medical technologies, primary care services expanded unabated, resulting in improved health outcomes. The combined effects of the well-functioning universal and equitable health care system in place before the crisis, the government's steadfast support for the system, and the network of social solidarity based on grassroots organizations mitigated the corrosive effects of monetary and market relations in the context of severe scarcities and an intensified U.S. embargo against the Cuban people.

Learning together: a Canada-Cuba research collaboration to improve the sustainable management of environmental health risks

OBJECTIVE

To build a national Cuban capacity for training environmental health professionals directly linked to the needs of policy-makers and communities.

PARTICIPANTS

The University of Manitoba and University of British Columbia collaborated with an established training centre in Cuba (the Instituto Nacional de Higiene y Epidemiologia--INHEM) and new centres in the Central (Santa Clara) and Eastern (Santiago) regions of the country.

SETTING

Cuba.

INTERVENTION

In the mid-1990s, a comprehensive curriculum (masters and diploma programs) was collaboratively developed, applying interactive teaching methods, and was delivered through a series of workshops and other interactions in Cuba, and short-term visits to Canada by Cuban PhD students.

OUTCOMES

The collaboration was successful in fulfilling capacity-building targets (over 50 Masters graduates, 467 Diploma graduates, over 30 trained core faculty in all regional centres as well as new curriculum and new accredited regional programs). Alongside this, a number of collaborative community-based research projects were undertaken in all three regions (drinking water in Santiago; housing and urban renewal, and dengue control in Havana; and tourism-related effects, and effective intersectoral management of population health determinants in Santa Clara).

CONCLUSION

The collaboration led to adopting new strategies for challenges such as a dengue epidemic in 2002, and new research on the effectiveness of intersectoral management of risks of particular interest to both Cuban and Canadian policy-makers. It triggered an ambitious collaboration between the Canadian-Cuban team and colleagues in Ecuador in order to build a similar national network there, built on South-South and North-South links.