Correspondence
Epidemic Optic Neuropathy in Cuba
N Engl J Med 1996; 334:1063-1064April 18, 1996
- Article
To the Editor:
The report by the Cuba Neuropathy Field Investigation Team (Nov. 2 issue)1 describes an excellent retrospective case–control study to determine the proximal causes of the epidemic of optic neuropathy in Cuba from 1991 through 1993. The causes included low micronutrient consumption and an excessive metabolic demand for B vitamins associated with the consumption of refined sugar, tobacco, and alcohol.
The report fails, however, as a public health analysis in that it does not address the more fundamental causes of the epidemic. These, like the causes of many outbreaks in the past, are to be found in socioeconomic conditions complicated by geopolitical issues. Similar epidemics occurred among prisoners of war and slaves and during the Spanish-American war in Cuba, because people were unable to cultivate their own food and received only semistarvation rations.2 The recent epidemic in Cuba is perhaps more alarming, because it is not an incidental result of the breakdown of a weak government in a poor country but the intentional result of political measures taken by the United States.
The structure of the Cuban economy from 1962 to 1990, with its heavy dependence on the Soviet Union, is a cause of Cuba's severe economic decline and lack of available nutrients in the 1990s. The country is restructuring its economy with diversified markets, locally produced goods, and a more sustainable level of consumption. After 1990, the major imports from Western countries were food and materials for the agricultural sector to enhance the production of food.
In 1992, the U.S. economic embargo was extended to prohibit Cuba from purchasing foods or medicines from U.S. firms and their subsidiaries abroad and to limit such sales from other countries. This extension of the embargo is a major contributing cause of the Cuban people's miseries. Many food imports were cut off; others became far more expensive. Because of the embargo, Cuba spends approximately 30 percent more for the medicines it purchases in the international market than it would if those medicines were purchased in the United States, and many modern medicines, produced only under U.S. patents, are unavailable for purchase at any price. The vitamins that were used as the initial intervention in the epidemic of peripheral neuropathy cost Cuba $151,000; they would have cost $56,000 and would have been available far more rapidly if they could have been purchased in Miami.3
These aspects of the embargo violate U.S. obligations under international law, which prohibits the denial of essential humanitarian goods to noncombatant populations. It is the only modern embargo that does not provide exemptions for the purchase of food and medicine.
The health community should join the Interamerican Commission on Human Rights of the Organization of American States, Americas Watch, and nearly every other government in the world in condemning these aspects of the embargo, which can only become worse as a result of recent events. At the same time, we can support scientific coordination such as that between the Centers for Disease Control and Prevention (CDC) and the Cuban Ministry of Health in investigating this epidemic. If allowed to do so, the medical community could promote a reasoned dialogue and effective diplomacy between Cuba and the United States.
3 ReferencesRichard Garfield, R.N., Dr.P.H.
Columbia University, School of Nursing, New York, NY 100321
The Cuba Neuropathy Field Investigation TeamEpidemic optic neuropathy in Cuba -- clinical characterization and risk factors. N Engl J Med 1995;333:1176-1182
Full Text | Web of Science | Medline2
Roman GC . On politics and health: an epidemic of neurologic disease in Cuba. Ann Intern Med 1995;122:530-533
Web of Science | Medline3
Adverse effects of the US economic embargo on the exercise of human rights in Cuba. Havana, Cuba: Ministry of Public Health, 1993.
To the Editor:
The authors of the study of the 1991–1993 epidemic of neurologic disease in Cuba state that it was caused by a combination of events, including the loss of Russian aid and a severe storm. They speculate about the factors contributing to the availability of food, including having relatives overseas. Unfortunately, the authors fail to mention that the U.S. government caused much of the problem. This failure is unexpected, because one of the members of the investigative team, G.C. Román, M.D., formerly at the National Institutes of Health, said in writing about the epidemic elsewhere that the U.S. government “contributed to its development, complicated its investigation and treatment, and continues to hamper its prevention.”1
How could this omission have occurred? Several of the authors were from the CDC. As employees of the U.S. government, they were required to have the manuscript cleared from the standpoint of policy before submitting it to the Journal (clearance policy for CDC publications, Form 0.576). Did political issues lead to the withholding of information about important causative factors in a major epidemic?
1 ReferencesAnthony F. Kirkpatrick, M.D., Ph.D.
University of South Florida, Tampa, FL 33612-47991
Roman GC . On politics and health: an epidemic of neurologic disease in Cuba. Ann Intern Med 1995;122:530-533
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We hope that collaborative investigations such as ours may form a bridge for ongoing scientific interchange between Cuba and the United States, as Dr. Garfield suggests. Our study represented the work of scientists from many organizations, including the Cuban Ministry of Public Health, the CDC, the Pan American Health Organization, Emory University, the Food and Drug Administration, and the National Institutes of Health. The manuscript was cleared by the Cuban government, as well as by the participating U.S. government agencies and the Pan American Health Organization. No information from our study was withheld for any reason, and the CDC clearance procedure did not result in any alteration in the content of the article.
Our study was not designed to evaluate the foreign policy of the United States or any other government and could not address the effect that the U.S. trade embargo may have had on the occurrence or characteristics of the epidemic. The impact of the embargo on the public health of the Cuban people has been addressed in a report by the American Public Health Association.1
It is important to emphasize that the purpose of the collaboration was the scientific investigation of identifiable risk factors for epidemic optic neuropathy. We found that the use of tobacco, especially cigar smoking, was strongly associated with an increased risk. Several nutritional factors, including higher serum concentrations of antioxidant carotenoids and higher reported dietary intake of vitamin B12, riboflavin, niacin, and methionine, were associated with a decreased risk. Increased sugar intake, higher levels of physical activity, and alcohol consumption were not associated with an increased risk. Although our study could not establish the definitive cause of the epidemic in Cuba, we hope that a better understanding of the risk factors involved will aid in the prevention of such occurrences anywhere in the future.
1 ReferencesRossanne M. Philen, M.D.
Atlanta, GA 30333for the CDC Members of the Cuba Neuropathy Field Investigation Team
