@ "I am not defending the Castro economic system."

Well, then, what? You're just being contrary? Because my entire point is that the Castro economic system is far more to blame than the embargo, so if you're arguing with me you sort of HAVE to address that issue, eh? :)

@ "Would you mind sharing your sources? I'm having a hard time finding what I would call reliable data."

Yeah, I hear you. You're not going to find "reliable data" because the Castro regime doesn't report any. They obfuscate, for obviously self-serving reasons. Thus, we must rely on other estimates. The ones I found for GDP ranged from about $60 billion to about $110 billion, so admittedly I used the higher end. But even using the lower end we're only talking about 1% of their economy lost to the embargo.

@ "The data I have found, however, is troubling to me, and I should think it would be even more troubling to you, a physician."

I'm more likely to blame the Castro regime, for reasons that I have already demonstrated. Would I like to go on a humanitarian mission to Cuba? Certainly! I'd have my worries about being sentenced to 30 years in some show-trial, though- I have a background in military intelligence. FWIW medical aid is allowed under current embargo regulations, especially after the changes in 2000 and 2009 removed many of the obstacles people used to complain about (one of the reasons that the US is still Cuba's fifth largest trading partner even with the embargo in place, as well as the number one source of Cuban food and agricultural imports), and Europe is perfectly capable of producing medical supplies, so arguing that the US is killing Cuban children is a bit delusional. Communism is killing Cuban children. But, in short, everyone is still trying to make a stink about the impact of the embargo on the Cuban medical system- on which I call BS, since medical supplies are ALLOWED under the current embargo. Read your own source- the Amnesty International paper. Even that first paper you cited was honest enough to say that the sad state of the Cuban economy is to blame-

"lack of currency made it difficult to purchase drugs and medical equipment from western Europe" after the Soviet subsidies ended.

They mention some very bad past policies that contributed too- "In 1983, I gave a lecture about HIV and was bluntly told that because homosexuality and intravenous drug usage did not exist in Cuba, AIDS would never become an meaningful issue." At least THAT has changed.

The authors try to blame much on shortages caused by the embargo, but frankly they don't do a good job of it. The "nutrient shortage?" well, if they had an functioning economy and cash reserves they could buy from Europe, which has a quite substantial medical infrastructure. The authors mention that such a large chunk of the pharmaceutical industry has ties to US companies- which is true- but there ARE other alternatives if Cuba were only able to show up with the cash. Even if the US would trade with them, they STILL couldn't buy the supplies. They'd basically rely on US humanitarian aid, because they'd still be unable to PAY for any of it. (Which is another issue- I'd LOVE to see the US send humanitarian missions to Cuba, but I'm not sure they'd accept it.)

And, Amnesty International? Yes, they call for an end to the embargo, but did you read their reasoning? Here's a quote from their opening abstract:

"The Cuban authorities portray non-violent political dissidents and human rights activists as foreign sympathizers supporting US policy against Cuba. The embargo has helped to undermine the enjoyment of key civil and political rights in Cuba by fuelling a climate in which fundamental rights such as freedom of association, expression and assembly are routinely denied."

and:

"Amnesty International believes that the impact of the embargo on the human rights of Cubans has received insufficient attention from the US government."

THAT'S their major issue with the embargo- with which I agree. It gives the regime excuses for repression. Most of that paper talks about "Economic and Social Rights", and the little bit it mentions about "Health Rights" is complaining about issues from the 1990s- before the 2000 and 2009 changes to the embargo, as they admit. I'm not even sure if I can say that the AI paper tries to make a case that the embargo is affecting Cuban healthcare (except for those dated 1990s references) so it is really just a call for an end to the embargo on the same grounds that I espouse. Thanks for the source. :)

@ "Do you really believe that? That they would go against the most powerful nation on earth merely to rant against unilateralism and schoolyard bullying?"

Do you REALLY believe otherwise? Really? You ACTUALLY believe that?

Am I making my point about how condescending that question was?

Anyway- yes, clearly when nations deal with one another it is on a rather juvenile level. They have tantrums, test nukes, detain UN inspectors, etc. I don't think you will ever go far wrong betting on the childishness of nations- was that you I had the argument with about Iran?

But I agree with the UN resolution's meta-issue: that the embargo should end. I'm just a bit more realistic about the motivation behind the grandstanding of some of those nations. And no I don't think that the primary motivation of very many of them was the suffering of Cuban children. Even Cuba!

EDIT-- But, clearly we're just at the point of repeating our arguments. I guess I'll bow out.

Edited by acrosome on 02/23/2013 12:08:32 MST.

"Well, then, what? You're just being contrary? Because my entire point is that the Castro economic system is far more to blame than the embargo, so if you're arguing with me you sort of HAVE to address that issue, eh? :)"

Contrary? Not at all. My point is that the issue is not quite that simple. The indirect effects of people not having access to medicines, which I think my links fairly well document, are one area where economic development has been impeded. The disruption of the very close economic ties between Cuba and the US post Batista made it extremely for the Cuban economy to progress, and would have been the case no matter what system Castro adopted. Being forced to rely on the technologically and economically backward USSR & co thereafter was another impediment to economic development. The reluctance of many Western companies to do business with Cuba for fear of US retaliation caused further problems. These are a few of the contributing factors, as I see it. The system Castro imposed doubtless is a major reason for Cuba's problems, but certainly not the only one. As I said earlier, we will never know how things would have turned out had we gone in with checkbooks blazing, but I am fairly certain in my own mind that the results would have been far better for both parties than the sorry mess we have on our hands today. We stand isolated with our moral credibility severely diminished and the Cuban people continue to suffer needlessly.


"Yeah, I hear you. You're not going to find "reliable data" because the Castro regime doesn't report any. They obfuscate, for obviously self-serving reasons. Thus, we must rely on other estimates. The ones I found for GDP ranged from about $60 billion to about $110 billion, so admittedly I used the higher end. But even using the lower end we're only talking about 1% of their economy lost to the embargo."

We have other means of gathering that information, satellites, human intelligence,
corporate espionage, etc. I find it interesting that this information is not publically available, which would enable folks like us to draw our own conclusions.
That the Cuban government obfuscates is entirely understandable. They do not want us to have an accurate picture of the damage the embargo has caused, and also do not want to own up to their own shortcomings. That the government of a supposedly free, transparent society obfuscates troubles me far more, because an informed citizenry is one of the bedrock requirements of a free society.

Edited by Ouzel: You mention 'only' a 1% loss. What would happen here in the US today if our economy took a 1% hit?


"I'm more likely to blame the Castro regime, for reasons that I have already demonstrated."

That you discount the informed judgement of several respected organizations composed of your peers also troubles me. Could you explain your reasoning in a bit more detail?

"Would I like to go on a humanitarian mission to Cuba? Certainly! I'd have my worries about being sentenced to 30 years in some show-trial, though- I have a background in military intelligence."

A valid concern. I wouldn't go either were I in your position, especially given our past attempts at subversion down there. It didn't end with The Bay of Pigs, you know.

"FWIW medical aid is allowed under current embargo regulations, especially after the changes in 2000 and 2009 removed many of the obstacles people used to complain about"

Under current regulations. That was not always the case.

"Europe is perfectly capable of producing medical supplies, so arguing that the US is killing Cuban children is a bit delusional."

But Cuba was not always capable of paying. There was a very difficult period after the USSR collapsed and Cuba was cast adrift. What was available was allocated to women and children and so it was primarily Cuban men who suffered. Earlier, foreign corporations, including pharmaceuticals, feared retaliation under US extraterritorial sanctions, and US producers of precursors used by foreign pharmaceutical manufacturers, feared prosecution even more, which led to shortages in Cuba. This is mentioned in the articles I linked to.

"Communism is killing Cuban children. But, in short, everyone is still trying to make a stink about the impact of the embargo on the Cuban medical system- on which I call BS, since medical supplies are ALLOWED under the current embargo. Read your own source- the Amnesty International paper. Even that first paper you cited was honest enough to say that the sad state of the Cuban economy is to blame- "

Under CURRENT regulations. It did not say that the sad state of the Cuban economy is the only source of blame.

As for calling BS, frankly, I'll go with the opinions of the American Society of Internal Medicine:

http://www.hawaii.edu/hivandaids/Effect_of_the_U.S._Embargo_and_Economic_Decline_on_Health_in_Cuba.pdf Sorry, I can't get the text to copy over. I think it's a restricted PDF. The author's conclusion is in her preface to the article. It is very much along the lines on the AJPH conclusion, below.


And The American Journal of Public Health: "CONCLUSIONS: To be consistent with international humanitarian law, embargoes must not impede access to essential humanitarian goods. Yet this embargo has raised the cost of medical supplies and food Rationing, universal access to primary health services, a highly educated population, and preferential access to scarce goods for women and children help protect most Cubans from what otherwise might have been a health disaster."





"The authors try to blame much on shortages caused by the embargo, but frankly they don't do a good job of it. The "nutrient shortage?" well, if they had an functioning economy and cash reserves they could buy from Europe, which has a quite substantial medical infrastructure. The authors mention that such a large chunk of the pharmaceutical industry has ties to US companies- which is true- but there ARE other alternatives if Cuba were only able to show up with the cash. Even if the US would trade with them, they STILL couldn't buy the supplies. They'd basically rely on US humanitarian aid, because they'd still be unable to PAY for any of it."

So it boils down to cash? How sad. Especially when the lack of cash is at least partially due to the embargo and the unfortunate shift of the Cuban economy to the Soviet model, which was at least partially the price extracted by the USSR for subsidizing them. this is NOT to absolve the Castros for their mistakes, but to reinforce my main theme, which is that the difficulties experienced by Cuba are not simply a result of Castro's mistakes.

"(Which is another issue- I'd LOVE to see the US send humanitarian missions to Cuba, but I'm not sure they'd accept it.)"

I think we might both agree that there is one way to find out.

"And, Amnesty International? Yes, they call for an end to the embargo, but did you read their reasoning? Here's a quote from their opening abstract:"

'the Cuban authorities portray non-violent political dissidents and human rights activists as foreign sympathizers supporting US policy against Cuba. The embargo has helped to undermine the enjoyment of key civil and political rights in Cuba by fuelling a climate in which fundamental rights such as freedom of association, expression and assembly are routinely denied.'

and:

'Amnesty International believes that the impact of the embargo on the human rights of Cubans has received insufficient attention from the US government.'"

That doesn't cancel out what they had to say about the impact of the embargo. I read all of the article and decided to use it precisely because of its even handed approach to the issue. I certainly am not defending the Castros' human rights record, nor can anything I posted be so construed. Note they mention this as one more unfortunate effect of the embargo. That way you can't accuse me of cherry picking my sources. ;0)

"THAT'S their major issue with the embargo- with which I agree. It gives the regime excuses for repression. Most of that paper talks about "Economic and Social Rights", and the little bit it mentions about "Health Rights" is complaining about issues from the 1990s- before the 2000 and 2009 changes to the embargo, as they admit. I'm not even sure if I can say that the AI paper tries to make a case that the embargo is affecting Cuban healthcare (except for those dated 1990s references) so it is really just a call for an end to the embargo on the same grounds that I espouse. Thanks for the source. :)"

Health care and economic rights are difficult to separate, and both occupy a secondary place in the US value system, behind freedom of speech, the right to bear arms, etc. That is not the case in most of the world. As even you admit, the embargo did have an impact on access to health care prior to 2000, an impact that is still being felt in Cuba today, as those who were affected are very likely to not be fully productive members of society. Early access to health care and nutrition are well known to affect physical and cognitive development. On this basis, one could build a case for another negative effect on the cuban economy if one were able to get into Cuba and gather the data, IMO. An epidemiologists wet dream. ;)

Glad you enjoyed the article. As a physician, what did you think of the other two, just out of curiosity?



"Do you REALLY believe otherwise? Really? You ACTUALLY believe that?

Am I making my point about how condescending that question was?"

Sorry, my righteousness got the better of me; I guess the Lord ain't finished with me yet. :( Here's the official EU position on the matter. It's a bit less condescending, but also a bit more nuanced than your schoolyard bully metaphor.

http://www.eu-un.europa.eu/articles/fr/article_5273_fr.htm

"Anyway- yes, clearly when nations deal with one another it is on a rather juvenile level. They have tantrums, test nukes, detain UN inspectors, etc. I don't think you will ever go far wrong betting on the childishness of nations- was that you I had the argument with about Iran?"

See immediately above for slightly more adult behavior, even though all it really proves is that you neglected to add greed to your litany of complaints about the state of international relations. ;0)

"was that you I had the argument with about Iran?"

Ah, how I long for the good old days. I had more fun with that one than even the Great Carbon Flame War, and have treasured our conversations ever since.

"But I agree with the UN resolution's meta-issue: that the embargo should end."

Darn near everybody agrees with you on this one, even here in the US.

"I'm just a bit more realistic about the motivation behind the grandstanding of some of those nations. And no I don't think that the primary motivation of very many of them was the suffering of Cuban children. Even Cuba!"

This one boils down to our differing views of human nature. I think I'm inclined to cut the human race a little more slack. But only a little. And I'll freely admit you have seen far more of the dark side than I. Who knows? Perhaps you're right, but I hope not.


"But, clearly we're just at the point of repeating our arguments. I guess I'll bow out."

Until next time, then. I enjoyed this one.

Edited by ouzel:

One last link, just because it's an interesting ground level account of the effects of the embargo by a Cuban who lived there until 2002. He is by no means a fan of the Castros, BTW. I found it a very informative, anecdotal account of how things played out and why.

http://www.joselatourauthor.com/2009/12/21/the-american-and-the-cuban-embargoes/

Edited by ouzel on 02/23/2013 18:05:12 MST.

Well, it's good to see that you're at least acknowledging that Cuba's economy is screwed. But you're sucking me back in...

@"You mention 'only' a 1% loss. What would happen here in the US today if our economy took a 1% hit?"

Uh... not much. The US GDP contracted by 9% in late 2008, which caused one hell of a crisis as we all know, but we didn't nationally fall to Cuba's level. But I'll be the first to admit that your choice of the US as a comparison was a bad one. In addition to having sane trade practices (because really what I'm talking about here is Cuba's INSANE trade practices) the US simply has a very large economy capable of absorbing such vicissitudes.

Iceland might be a better comparison- a small, isolated island nation. Their entire banking industry failed and THEY weren't reduced to living on 2400 calories a day. They lived on stuff like rotten shark but, hell, they do that at baseline. :)

@"Could you explain your reasoning in a bit more detail?"

I have already addressed every question you raise. Please don't troll me.

@"Under current regulations. That was not always the case."

Yet all of the negative papers you're citing cite the 1990s. Heck, the one you really seem to like from Ann In Med was published in 2000, before the reforms. So yes, things actually do change, and frankly it is VERY hard to be critical about the modern form of the embargo regarding medical, humanitarian, and agricultural materials. The US is the single largest agricultural importer to Cuba, remember? And those reforms have been in place for over a decade! And even before that the same exceptions existed, but the world's humanitarian-industrial complex complained that the paperwork required was too onerous. (On which I call BS.) But, it got corrected, at any rate.

@"Under CURRENT regulations. It did not say that the sad state of the Cuban economy is the only source of blame."

It sure talks it up much more than anything else, and cites exactly what State did- a legacy of insane trade policy coupled with over-reliance on Soviet aid and foreign debt.

@"That you discount the informed judgement of several respected organizations composed of your peers also troubles me."
@"As for calling BS, frankly, I'll go with the opinions of the American Society of Internal Medicine:"

Well, let's actually get this one right. That's the paper I was talking about, published in 2000, before the reforms. And it was NOT any sort of consensus statement on the part of the Society as you seem to think- so really you're placing all of your faith in a SINGLE author, Michele Barry. Who, it turns out, relied heavily on official Cuban statistics. (It took me a while to read through all of the references.) He seems like a rather admirable guy in general; he helps run the Global Health Corps. But that probably does color his outlook, though- he wants unrestricted access to Cuba.

But, anyway, you are NOT "going with the opinions of the American Society of Internal Medicine." Let's make that clear. You're going with the opinions of Michele Barry. Yes, his paper passed peer-review, which just means that his data analysis probably wasn't flawed but does not discount the questionable source of his data. You'd be shocked at some of the stuff that gets past peer-review in medical journals.

@"That doesn't cancel out what they had to say about the impact of the embargo. I read all of the article and decided to use it precisely because of its even handed approach to the issue."

True. But they say almost nothing about the impact of the embargo, whereas they go on for PAGES about economic rights, etc. I'm just saying that this is what their real concern is. If they were concerned about the medical situation in Cuba they would have given the issue more than a few paragraphs in that monstrously large paper. Truly- I'm not kidding here- that paper sounds much more like MY argument than yours. They're saying that the embargo only serves to prop up the Castros.

@"As even you admit, the embargo did have an impact on access to health care prior to 2000, an impact that is still being felt in Cuba today,..."

Ah, no. The embargo had exceptions even before 2000- they just required a bit more effort from the NGOs, who basically abandoned the issue. And, frankly, if Cuba can't turn things around in a decade that says something about their economy, doesn't it? Their economy and trade practices remain f-ed up, which is not the fault of the embargo.

@"Here's the official EU position on the matter. It's a bit less condescending, but also a bit more nuanced than your schoolyard bully metaphor."

More nuanced, yes, but my metaphor was essentially correct, given that source. And also, note how critical they are of the Castro regime as a source of Cuban ills. I actually don't find ANYTHING in that which addresses the impact of the embargo except for two throw-away sentences near the end. They're just addressing their distaste of unilateralism. Like I said.

@"This one boils down to our differing views of human nature. I think I'm inclined to cut the human race a little more slack."

Humans I'm willing to cut some slack, but we're not talking about humans- we're talking about GOVERNMENTS, about which I am endlessly suspicious. The sole purpose of all governments is to perpetuate itself, nothing else.

@"One last link, just because it's an interesting ground level account of the effects of the embargo by a Cuban who lived there until 2002. He is by no means a fan of the Castros, BTW. I found it a very informative, anecdotal account of how things played out and why. "

Uh, so have I convinced you or something? Because that link looks like a long analysis of everything that's wrong with the Cuban economy and I lost track of how many times it says "The American embargo had nothing to do with this." (Direct quote.) Actually, it does mention some things the embargo did, but none seem very relevant to what we're discussing- tooling and the like. It is damned interesting reading, though, I'll give you that. I'll sit down with it in more detail when I have the time.

But if by some miracle anyone other than Tom and I are still here, you really should read that last link he provided. Yes, the author CLEARLY has his biases, but as Tom said it's interesting to get some insight from someone who lived in Cuba until 2002.

Edited by acrosome on 02/26/2013 08:04:30 MST.

"Well, it's good to see that you're at least acknowledging that Cuba's economy is screwed. But you're sucking me back in..."

;0)

"@"You mention 'only' a 1% loss. What would happen here in the US today if our economy took a 1% hit?"

Uh... not much. The US GDP contracted by 9% in late 2008, which caused one hell of a crisis as we all know, but we didn't nationally fall to Cuba's level. But I'll be the first to admit that your choice of the US as a comparison was a bad one. In addition to having sane trade practices (because really what I'm talking about here is Cuba's INSANE trade practices) the US simply has a very large economy capable of absorbing such vicissitudes."

That was back when we were riding high before the bubble burst, with a much larger, more diversified economy than Cuba's. Fast forward to the present, when our economy is a bit wobbly and the clowns in D.C. are getting ready to drive it into the ditch. There are all sorts of dire predictions about how this may turn out, and even a few relatively rosy ones similar to yours. But the preponderance of opinion seems to be that the CBO's predicted 1.4% drop in economic output that will result if the sequestration continues until year's end will put us back into recession. Not much? I would disagree. Although I admit that 1.4% is not 1%. ;)

"@"Could you explain your reasoning in a bit more detail?"

I have already addressed every question you raise. Please don't troll me."

I'm not trolling you, and you haven't addressed every question I raised, as you implicitly admit by addressing the article in The American Journal of Internal Medicine, below. And you still haven't addressed the article in The American Journal of Public Health.

@"Under current regulations. That was not always the case."

Yet all of the negative papers you're citing cite the 1990s. Heck, the one you really seem to like from Ann In Med was published in 2000, before the reforms. So yes, things actually do change, and frankly it is VERY hard to be critical about the modern form of the embargo regarding medical, humanitarian, and agricultural materials. The US is the single largest agricultural importer to Cuba, remember? And those reforms have been in place for over a decade! And even before that the same exceptions existed, but the world's humanitarian-industrial complex complained that the paperwork required was too onerous. (On which I call BS.) But, it got corrected, at any rate."

In other words you only want to assess the impact of the embargo post 2000, and not back when it did its real damage? As I see it, there were 2 critical periods when the embargo had a huge impact on Cuba, in the 1960's and then the 1990's , after the collapse of the USSR. Those are the periods addressed in the articles I cited, and in the last article by Jose Latour in the final article I linked you to. I will copy his comments here to refresh your memory, as you seemed to find him supportive of your position:

'Its effects were extremely prej­u­di­cial in the early 1960s.'

'Yet, to their com­plete sur­prise Cubans dis­cov­ered that even though Soviet space explo­ration tech­nol­ogy was cut­ting edge, the U.S.S.R. lagged forty or fifty years behind Amer­i­can know-how in almost every­thing else. Russ­ian internal-combustion engines guz­zled three times more fuel than Amer­i­can engines. Size was a fac­tor fre­quently over­looked in Com­mu­nist indus­trial design, so walls had to be demol­ished, pipes re-laid, to make space for much big­ger elec­tric motors, pumps, etc. Stan­dards were dif­fer­ent in prac­ti­cally every­thing, from screws and nuts to tele­vi­sion sta­tions. To fur­ther com­pound the prob­lem, the Soviet economy’s rigid plan­ning cre­ated obsta­cles that could only be sur­mounted when Moscow’s polit­i­cal estab­lish­ment egged on its state-owned com­pa­nies to serve orders filled by the new ally.'

Such was the disruptive impact of the embargo on a then particularly vulnerable Cuban economy that had been dependent on US machinery, technology, etc prior to the embargo.

"@"That you discount the informed judgement of several respected organizations composed of your peers also troubles me."
@"As for calling BS, frankly, I'll go with the opinions of the American Society of Internal Medicine:"

Well, let's actually get this one right. That's the paper I was talking about, published in 2000, before the reforms. And it was NOT any sort of consensus statement on the part of the Society as you seem to think- so really you're placing all of your faith in a SINGLE author, Michele Barry. Who, it turns out, relied heavily on official Cuban statistics. (It took me a while to read through all of the references.) He seems like a rather admirable guy in general; he helps run the Global Health Corps. But that probably does color his outlook, though- he wants unrestricted access to Cuba.

But, anyway, you are NOT "going with the opinions of the American Society of Internal Medicine." Let's make that clear. You're going with the opinions of Michele Barry. Yes, his paper passed peer-review, which just means that his data analysis probably wasn't flawed but does not discount the questionable source of his data. You'd be shocked at some of the stuff that gets past peer-review in medical journals."

I'll try to deal with this one as one package, since you seem to be treating the entire peer review process pretty cavalierly. Here is a reply to a query I sent to a friend who is a clinical professor of psychiatry at a major university, and himself the author of a number of peer reviewed articles published in scientific journals:

"All articles that are submitted to a peer reviewed journal are reviewed by at least 3 and usually 5 independent experts in the field. They're not reviewed by the editors or by the editorial staff except for formatting etc. once an article has been accepted. The 3 to 5 reviewers are asked to look at the article in its entirety: relevance, contribution, methodology, data collection, data analysis, data interpretation, strengths, weakness, conflict of interest, references, etc., etc.

The article can be out right rejected, asked for modification in response to all reviewers comments, reanalyzed, resubmitted, and very rarely accepted after the 1st run through the reviewers. Unless every single reviewer's comment is addressed and the appropriate modifications made in the manuscript, it is unlikely to ever be accepted.

Finally, there has been a unification of the rules across all peer-reviewed journals that this protocol is pretty much followed by everyone.

The editors are responsible for everything that is published but they only do so after this rigorous process has been completed."

Given these comments by one who has been thru the process many times, I question your comments about the quality of Barry's data. Whether or not his conclusions reflect the opinions of the American Society of Internal Medicine I cannot know, but I would be surprised if they dismissed his article and its conclusions as cavalierly as you have, given the rigorous process it was subject to before being published. By the way, there are numerous articles on the same subject in PubMed, drawing pretty much the same conclusions. You can look them up if you're interested.

"@"That doesn't cancel out what they had to say about the impact of the embargo. I read all of the article and decided to use it precisely because of its even handed approach to the issue."

True. But they say almost nothing about the impact of the embargo, whereas they go on for PAGES about economic rights, etc. I'm just saying that this is what their real concern is. If they were concerned about the medical situation in Cuba they would have given the issue more than a few paragraphs in that monstrously large paper. Truly- I'm not kidding here- that paper sounds much more like MY argument than yours. They're saying that the embargo only serves to prop up the Castros."

What I'm after is as close an approximation of the truth as we can, between us, come up with. To that end, I have no qualms about including data that supports your position as well as mine. In this case, it does both. They obviously have problems with the behavior of both the US and Cuba. Economic rights and access to health care are intertwined, IMO, simply because health care is a function of an economy. It requires resources that cost money, simply put, and are produced by various sectors of an economy.

@"As even you admit, the embargo did have an impact on access to health care prior to 2000, an impact that is still being felt in Cuba today,..."

"Ah, no. The embargo had exceptions even before 2000- they just required a bit more effort from the NGOs, who basically abandoned the issue. And, frankly, if Cuba can't turn things around in a decade that says something about their economy, doesn't it? Their economy and trade practices remain f-ed up, which is not the fault of the embargo."

Exceptions that Cuba couldn't pay for in the economically chaotic period after the abrupt withdrawal of Soviet support. That is the period the articles I cited deal with.

"@"Here's the official EU position on the matter. It's a bit less condescending, but also a bit more nuanced than your schoolyard bully metaphor."

More nuanced, yes, but my metaphor was essentially correct, given that source. And also, note how critical they are of the Castro regime as a source of Cuban ills. I actually don't find ANYTHING in that which addresses the impact of the embargo except for two throw-away sentences near the end. They're just addressing their distaste of unilateralism. Like I said."

Beyond unilateralism, there are important legal questions like extra territoriality, in this case subjecting foreign companies to US law and banning foreign ships that have docked in Cuban ports within 6 months. This is not throw away stuff, Dean. Nor is their moral outrage at the impact of the embargo on health care in Cuba. You don't get in excess of 180 nations voting against the most powerful nation on earth in the UN year after year without some substance to their disapproval. It is no surprise that it is also reflected in the official EU position as well.

"Humans I'm willing to cut some slack, but we're not talking about humans- we're talking about GOVERNMENTS, about which I am endlessly suspicious. The sole purpose of all governments is to perpetuate itself, nothing else."

Governments are conceived by people, administered by people, and in many cases act in the perceived best interests of the people they govern. Many are actually chosen by the people these days. Many are also corrupt, not by design but due to the nature of the people who administer them. I don't see how you can separate the two. In any case, governments are the best thing we have been able to come up with to date to keep us from the law of the jungle. What would you propose as an alternative?

"Uh, so have I convinced you or something? Because that link looks like a long analysis of everything that's wrong with the Cuban economy and I lost track of how many times it says "The American embargo had nothing to do with this." (Direct quote.) Actually, it does mention some things the embargo did, but none seem very relevant to what we're discussing- tooling and the like. It is damned interesting reading, though, I'll give you that. I'll sit down with it in more detail when I have the time."

As I said above, I am interested in getting a better understanding of the subject, and if that means including data that you can use against me, so be it. I'm more interested in the truth than winning a debate. But for me, the issue is decidedly more nuanced than you seem to see it. As I said early on, I am no defender of the Castros' performance, but neither can I defend our odious behavior which, in addition to driving the Castros into the arms of the Soviets, caused enormous unnecessary suffering for the Cuban people. Better we had engaged them and tried to influence their path peacefully. Check books blazing, student exchanges, cultural exchanges, that kind of touchy feely stuff. Instead, we let macho pride and a cabal of Cuban
expats lead us into a fiasco that has tarnished our reputation worldwide and helped perpetuate a humanitarian disaster.

Sucking me in again... But seriously, we're just repeating ourselves, so I'll limit commentary to a few points:

@ "I'm not trolling you, and you haven't addressed every question I raised.."

OK- that was meant to be a bit tongue-in-cheek (I should've smilied) but statements like that often are a troll, even if unintentional. It implies that the other person has the burden of proof, and they have to expend time and effort composing a response while you just get to sit back and be reactionary. REAL trolls do it so that they can suck up time and attention from people- which is what they want.

I think I've explained my reasoning well enough. If you truly don't understand my argument it's due to cognitive dissonance or something. It's a rational argument. We simply disagree.

@ "In other words you only want to assess the impact of the embargo post 2000, and not back when it did its real damage? As I see it, there were 2 critical periods when the embargo had a huge impact on Cuba, in the 1960's and then the 1990's , after the collapse of the USSR. Those are the periods addressed in the articles I cited,"

So, yes, you're citing old data. :)

But, seriously, if you're going to criticize the embargo then yes you should criticize the current form. Doing otherwise is like criticizing US voting laws by attacking Jim Crow- it's old news. There have been essentially no roadblocks to medical or agricultural trade between the US and Cuba for over a decade and relatively few even before that, which completely nullifies the supposed "humanitarian" argument against the embargo. There are better arguments, as I have been endorsing. I'm also not saying that the embargo had NO effect on the Cuban economy- heck, I quantified it! I gave you a dollar figure. But it isn't enough to explain why Cuba's economy is in the toilet. Did the embargo cause annoying hardships involving re-gauging all of the pipes? Yeah, I imagine it did. But this did not sink the Cuban economy. The Cuban government sank the Cuban economy. You keep asking me to read papers from medical journals; did you read the parts of the State Department paper and the Amnesty International paper that spell out the ridiculous policies of the Cuban government which led to the death of their economy? You say that my analysis lacks complexity- I'll turn that around and say that perhaps you need a more complex take on the issue, too, than just "the embargo is to blame!"

You asked why I'm not placing much stock in medical journals. Ok. Those medical journal papers that you tout understandably focus on one issue- that healthcare in Cuban is declining. Which it is. They make a few token attempts to explain this via the embargo but, brother, these are NOT insightful economic analyses. Are you really going to accept a paper in a medical journal as an authority on the Cuban economy? Cuba has less and less medical infrastructure because they can't PAY for it, not because of the embargo. So, regarding the Cuban economy and why it is in such poor shape I'll stick with the Department of State and the US Chamber of Commerce.

Because I think that's the nut of our disagreement- the degree to which the embargo killed the Cuban economy. Am I wrong? Because access to medical supplies is not an issue- they have it. They just can't PAY for it.

If you want to convince me you'll have to find reputable economic analyses, not medical ones. And, yes, I'm suspect of the UN- academic sources would be better. Seriously, I'm not being persnickety- that might move my opinion. But even then I suspect that we would just start producing papers with conflicting conclusions, and in a field in which I'm not any great authority and thus much less able to critique them intelligently, so I'm not sure their would be any point. Unlike below:

@ "Given these comments by one who has been thru the process many times, I question your comments about the quality of Barry's data."

As someone who is familiar with the medical literature and the peer-review process I will assure you that a LOT of garbage gets published, especially on subjects with a clear political angle. If you or your psychiatry friend try to tell me otherwise I will laugh in your faces. (A good though nonpolitical example that I just discussed with my partners recently are all of the papers that supposedly "proved" that laparoscopic inguinal hernia repairs cost less and have quicker return-to-work times than open hernia repairs. Ha! Cui bono? I'll tell you who- the MIS surgeons!) Barry's paper remains a single-author paper with a few interesting anecdotes but with much of it's conclusions based on data from questionable sources. Now, a lot of papers are published with imperfect data- that's life. We often have nothing better, and we have to base decisions on something. But it's not an invalid criticism. The reviewers check a lot things, including the integrity of data- meaning that they try to see if it looks fictional. Barry chose to use data derived from Cuban sources. It's "valid" official data per se, but a rational person would still question it. (Christ, I do HOPE you question it...) Also, a medical paper written by a doctor is not necessarily a reliable economic analysis, as I mentioned above.

@ "Beyond unilateralism, there are important legal questions like extra territoriality, ... This is not throw away stuff, Dean."

And I'm not saying that it is. There are many GREAT arguments that the embargo has to go. I merely maintain that Cuba's decrepit economy isn't one of them- that's on the Cubans.

You're sort of preaching to the choir on this one. I'm not sure what your point is- I AGREE with you on this stuff. Just not that the embargo has throttled Cuba's economy, and it's their economy that I blame for their unfortunate humanitarian issues.

Edited by acrosome on 03/01/2013 12:05:37 MST.

"But seriously, we're just repeating ourselves, so I'll limit commentary to a few points:"

Agreed. I think we're about ready to call it a day on this one, so I'll be brief as well.

"OK- that was meant to be a bit tongue-in-cheek (I should've smilied) but statements like that often are a troll, even if unintentional. It implies that the other person has the burden of proof, and they have to expend time and effort composing a response while you just get to sit back and be reactionary. REAL trolls do it so that they can suck up time and attention from people- which is what they want."

In a back and forth discussion like ours, when a person cites sources, the burden IS on the other person to react, as you rightly pointed out to me when I neglected to read your link to the State Dept report. It's how such discussions are conducted if they are to avoid merely exchanging opinions. But as long as you don't think I'm
a real troll, I'll let it go at that. ;)

"I think I've explained my reasoning well enough. If you truly don't understand my argument it's due to cognitive dissonance or something. It's a rational argument. We simply disagree."

I think by now I understand your argument perfectly well, and it is a rational one. I just don't entirely agree with it. Your focus has been on the impact of the embargo on the Cuban economy in general, while mine has been focused more on the impact of the embargo on Cuban health care, and secondarily on its impact on the Cuban economy in general.

"So, yes, you're citing old data. :)" Definitely, because the impact of the embargo
at those critical times had effects that last to this day. As Jose Latour, who you cite as supporting your argument said, the impact was particularly severe in the 60's just after the revolution. This put the Cuban economy behind the 8 ball from the very beginning and forced them into the arms of a waiting USSR with disastrous long term consequences for reasons you and I mostly agree on, as can be seen from the downward spiral of the Cuban economy after the USSR withdrew its support in the early 90's. The Torricelli and Helm-Burton Acts were crafted precisely to take advantage of this, and the timing was no accident. This period is the one which the medical articles I cited address, with justifiable, IMO, moral outrage, given the oath all physician take. As I said, there are more articles out on PubMed along the same lines.

"But, seriously, if you're going to criticize the embargo then yes you should criticize the current form."

And I do, although for a different reason: It is a foreign policy disaster, particularly in the aftermath of our Iraq debacle, in which I include the embargo we imposed on them during the 90's. We are squandering our moral credibility at a time when it is most needed if we are to avoid being reduced to brute force as a way of pursuing our foreign policy objectives. One morally illegitimate embargo is bad enough, but the two of them together have earned us an incredible amount of enmity around the world. We can ill afford to continue along this path, IMO. BTW, Hillary reaffirmed her support for the embargo a couple of weeks ago in one of her last public appearances. :(


"There have been essentially no roadblocks to medical or agricultural trade between the US and Cuba for over a decade and relatively few even before that, which completely nullifies the supposed "humanitarian" argument against the embargo."

Here we disagree.

I'm also not saying that the embargo had NO effect on the Cuban economy- heck, I quantified it! I gave you a dollar figure. But it isn't enough to explain why Cuba's economy is in the toilet. Did the embargo cause annoying hardships involving re-gauging all of the pipes? Yeah, I imagine it did."

Mr Latour seemed to think they were more than annoying.

"But this did not sink the Cuban economy."

It hamstrung it at a critical time and forced them down a path that completed the job
by making them dependent on the USSR and its unworkable economic system to survive.
So, I would posit that in that sense it contributed hugely to sinking the Cuban economy. You can say the cuban Government sank the Cuban economy, and in one sense that is partially true, but what was their alternative at the time?

"You keep asking me to read papers from medical journals; did you read the parts of the State Department paper and the Amnesty International paper that spell out the ridiculous policies of the Cuban government which led to the death of their economy?"

Yes, I read them all, and I will be the first to agree that Castro's policies contributed hugely to the sorry state of the Cuban economy. However, as I said immediately above, what choice did they have in the beginning? After they accepted the Soviet economic model in return for aid and protection, the die was pretty much cast. That they had to do this was largely in response to the initial impact of the embargo and a constant threat of invasion by the US/proxies. You do remember the Bay of Pigs and attempted assassination of Fidel Castro during JFK's brief administration?

"You say that my analysis lacks complexity- I'll turn that around and say that perhaps you need a more complex take on the issue, too, than just "the embargo is to blame!""

I have never said that the embargo is entirely to blame anywhere in my posts to this thread, merely that it was a bigger factor than you state. Is the above reasoning complex enough for you? I don't expect you to agree with it, but it has been a recurrent theme running thru my posts from the beginning.

"You asked why I'm not placing much stock in medical journals. Ok. Those medical journal papers that you tout understandably focus on one issue- that healthcare in Cuban is declining. Which it is. They make a few token attempts to explain this via the embargo but, brother, these are NOT insightful economic analyses. Are you really going to accept a paper in a medical journal as an authority on the Cuban economy?"

Nope, just an authority on Cuban health care. Hopefully we can agree that the 3-5 reviewers of the article were selected for their expertise in the field? Do you have any reason to question their credentials? Otherwise, it seems to me you are calling the entire peer review process into question.

"Cuba has less and less medical infrastructure because they can't PAY for it, not because of the embargo. So, regarding the Cuban economy and why it is in such poor shape I'll stick with the Department of State and the US Chamber of Commerce."

Again, I'll go back to that initial period after the revolution, when they were forced down a disastrous path.

"Because I think that's the nut of our disagreement- the degree to which the embargo killed the Cuban economy. Am I wrong?"

Precisely.

"Because access to medical supplies is not an issue- they have it. They just can't PAY for it."

If you can't pay for it, you can't access it. Just like here in the USA. Does that make it right? Not in the view of a vast majority of the nation of the world, where access to health care is ocnsidered a basic human right. To the degree we are perceived as being largely responsible for that sad state of affairs, we have a major foreign policy disaster on our hands.

"If you want to convince me you'll have to find reputable economic analyses, not medical ones."

I've done about as much as I have time for. I rest my case.

"And, yes, I'm suspect of the UN- academic sources would be better. Seriously, I'm not being persnickety- that might move my opinion. But even then I suspect that we would just start producing papers with conflicting conclusions, and in a field in which I'm not any great authority and thus much less able to critique them intelligently, so I'm not sure their would be any point. Unlike below:"

Pretty much why I feel like I would be wasting my time digging up academic sources, especially given your reaction to my medical sources.

"As someone who is familiar with the medical literature and the peer-review process I will assure you that a LOT of garbage gets published, especially on subjects with a clear political angle."

That's odd; I thought it was a humanitarian issue regarding access to health care.

"If you or your psychiatry friend try to tell me otherwise I will laugh in your faces. (A good though nonpolitical example that I just discussed with my partners recently are all of the papers that supposedly "proved" that laparoscopic inguinal hernia repairs cost less and have quicker return-to-work times than open hernia repairs. Ha! Cui bono? I'll tell you who- the MIS surgeons!)"

Laugh, if you will. I can take it, and my friend could care less. ;0) My response would be that the exception proves the rule. Again, unless you are calling the entire process, which is the best the scientific community has been able to come up with to date, suspect, it would seem that you would give a certain deference to a peer reviewed article barring concrete evidence to the contrary. Else why bother citing sources in the first place? Which is what we have been doing throughout this thread. My 2 cents


"Barry's paper remains a single-author paper with a few interesting anecdotes but with much of it's conclusions based on data from questionable sources. Now, a lot of papers are published with imperfect data- that's life. We often have nothing better, and we have to base decisions on something. But it's not an invalid criticism. The reviewers check a lot things, including the integrity of data- meaning that they try to see if it looks fictional. Barry chose to use data derived from Cuban sources. It's "valid" official data per se, but a rational person would still question it. (Christ, I do HOPE you question it...) Also, a medical paper written by a doctor is not necessarily a reliable economic analysis, as I mentioned above.

The reviewers, presumably selected for their expertise, didn't seem to think the sources were questionable enough to refrain from citing them. What would be your grounds for deeming them questionable, other than that they are Cuban? As you said, we have to base decisions on something. I might question the sources but, lacking the necessary expertise, I would still tend to give deference to 3-5 independent experts unless I had equally competent sources who held otherwise. As I mentioned above it was, IMO, an analysis of a health care situation, not a larger economic analysis.

"And I'm not saying that it is. There are many GREAT arguments that the embargo has to go. I merely maintain that Cuba's decrepit economy isn't one of them- that's on the Cubans.

You're sort of preaching to the choir on this one. I'm not sure what your point is- I AGREE with you on this stuff. Just not that the embargo has throttled Cuba's economy, and it's their economy that I blame for their unfortunate humanitarian issues."

We'll just have to disagree on tis one, at least partially. I think part of our disagreement is which time frame we use to assess the embargo's impact, and partly how much the decrepit state of Cuba's economy is responsible for the health care issues.

Thanks for another interesting exchange.

Edited by ouzel on 03/01/2013 16:35:28 MST.

"so I'll be brief as well."

http://www.youtube.com/watch?v=G2y8Sx4B2Sk

Re" brevity. Yes, clearly Tom and I both have problems with this...

I have to tell you, Tom, that the constant trumpeting about "3-5 experts in the field" strikes me as a great bit of obfuscation of the patent fact that Barry is arguing an economic issue in a medical publication. And that's really what it comes down to.

Clearly there ARE failures of your "3-5 experts", since clearly garbage does get published. Not to mention all of the CONTRADICTORY stuff that gets published- how can they BOTH be right? Yet both passed peer review... Jesus- I can't tell you how much garbage is out there. Seriously- talk to your psychiatry friend, again, and ask him about the bad papers that get published. If he's being honest he'll tell you. How many "experts" on Cuban healthcare and economy do you suppose Ann In Med could scrape up for that one? Really? On a subject like outcomes from bariatric surgery, yes, it is easy to produce a ton of reviewers who can critique intelligently and in an unbiased way, but not on this! And if they could find some that might qualify as "experts" they undoubtedly would have humanitarian backgrounds themselves, and thus share his desire for an open Cuba. And they'd still be more experts on delivery of humanitarian aid than on embargo effects. More likely, though, these reviewers weren't of any particular expertise on the subject. I do understand why Ann In Med published that paper- all journals publish the equivalent of a "human interest story" now and then. They're fun. But Barry's conclusions should have been something along the lines of "healthcare in Cuban has been in a steady decline", rather than "the embargo is killing Cuban healthcare." Because he didn't PROVE the latter. But stuff like that slips through in conclusions ALL THE TIME.

Talk to you friend about the peer review process some more. It's the best we have, yes, but it isn't perfect, and medical journals are just as guilty as anyone else about trumpeting agendas. And if as you claim you don't understand how this has an agenda then, well, you don't understand that.

Edited by acrosome on 03/06/2013 10:13:23 MST.

"I have to tell you, Tom, that the constant trumpeting about "3-5 experts in the field" strikes me as a great bit of obfuscation of the patent fact that Barry is arguing an economic issue in a medical publication. And that's really what it comes down to."

And here I thought he was arguing about the impact of an economic issue on health care, the latter of which is a legitimate issue for the journal to be concerned with.

"How many "experts" on Cuban healthcare and economy do you suppose Ann In Med could scrape up for that one? Really?"

I don't know, Dean. Do you have any idea? Seriously. Ideally, they would be assembled from international sources, the WHO perhaps, but I'd speculate that in this case they were probably from the US. But even if the supply was limited, how does that impugn their expertise? Ultimately, if Ann In Med wants to maintain its reputation as a reputable journal, it can't go around publishing garbage, can it? Given the intense animosity toward the Castro regime here in the US, I should think there would have been an immediate and overwhelmingly critical response if the article was as far off the mark as you seem to assume.

"Seriously- talk to your psychiatry friend, again, and ask him about the bad papers that get published. If he's being honest he'll tell you."

This guy is my best friend, so there is no question of honesty involved. I will definitely inquire as to the frequency of garbage in peer reviewed journal, though, as you have piqued my curiosity. It may be that I phrased my original question to him too narrowly.

"but not on this! And if they could find some that might qualify as "experts" they undoubtedly would have humanitarian backgrounds themselves, and thus share his desire for an open Cuba. And they'd still be more experts on delivery of humanitarian aid than on embargo effects. More likely, though, these reviewers weren't of any particular expertise on the subject."

This is where I start to have trouble with what you are saying. You are making a lot of unsubstantiated assumptions in an effort to destroy the credibility of the source I linked you to. How do you know the sources had no particular expertise, and why would a journal Ann In Med put its reputation on the line by publishing garbage? Again, seriously, why would they do that?

"But Barry's conclusions should have been something along the lines of "healthcare in Cuban has been in a steady decline", rather than "the embargo is killing Cuban healthcare." Because he didn't PROVE the latter. But stuff like that slips through in conclusions ALL THE TIME."

AS I asked above, why wasn't there a response along those lines from experts espousing your point of view, given the controversial nature of the subject? I should think the Cuban expat crowd, among others, would have jumped all over that one. It just doesn't compute, at least not to me. As you say, there are all sorts of peer reviewed articles coming to exactly the opposite conclusions. Why not in this case? Also, as I mentioned in my last post, there are a number of other articles arriving at pretty much the same conclusions over on PubMed. Where are the peer reviewed countervailing arguments?

"Talk to you friend about the peer review process some more. It's the best we have, yes, but it isn't perfect, and medical journals are just as guilty as anyone else about trumpeting agendas. And if as you claim you don't understand how this has an agenda then, well, you don't understand that."

Agreed, not perfect but the best we have, which is why I cited articles written under its protocols. It was the best I could find to support my point of view, and certainly better than my opinion. What else would you have me do? Can you point me to any peer reviewed articles, or other academic sources to support your point of view? I promise to read them if you do. But, so far, all I am hearing from you is how flawed the process is and how biased the author is. Yes, the author probably does have an agenda, as do many physicians familiar with the embargo on humanitarian grounds, but he submitted his article to presumably dispassionate, neutral review, and it was passed. I suppose the jury could have been stacked, but it seems a stretch to me. Again, the journal's reputation would potentially be on the line.

In any case, I will definitely talk more with my friend about the review process, for my own enlightenment. Like I said, I am more interested in the truth here than in being right.

Getting briefer. ;0)

Ultimately, if Ann In Med wants to maintain its reputation as a reputable journal, it can't go around publishing garbage, can it?

That assumes it is able to tell the difference, but "garbage" may be taking things a bit far. To briefly jump in on the issue of journal articles, I'll toss in a few links.

First, an account of reproducibility issues increasingly cropping up in science can be found here:
http://online.wsj.com/article/SB10001424052970203764804577059841672541590.html

In case that was behind a paywall, this Reuters piece is more entertaining:
http://www.reuters.com/article/2012/03/28/us-science-cancer-idUSBRE82R12P20120328

Short summary: Most results can't be reproduced. Many causes may be benign, but there's a huge pressure for scientists to publish, and a massive volume of papers. For industry or venture capitalists, that means anything coming out of academia needs to be verified before it can be trusted to base a project on.

@ Jeremy- that's more of an issue in basic science, I suspect. And, usually you can spot the papers with clear commercial bias. But, no, IMO "garbage" is not too strong a word for some stuff I see in medical journals.

I've discovered that when a layman tries to cite a medical article, it's usually a BAD one. Kind of like how bad money drives out good, or something. A great example was that one paper about vaccines and autism from Lancet, which was horrible. The authors retracted and disavowed it (after the lead author was found guilty of misconduct), the editor admitted it never should have gotten published, etc., yet it is still cited on all the wingnut websites.

But I'll grant you this- I've been taught to be very critical of journal articles, so perhaps my suspicious nature colors my outlook. My residency program hit that subject pretty hard. If you're going to be practicing medicine you've got to be able to spot BS. I am definitely capable of going through a paper and deciding if it's a "good" one or not. And, yes, there are a lot of "not good" ones out there. That's the simple truth. I will also grant you this: Ann In Med is a higher-end journal, so probably less garbage, but also certainly not garbage-free.

A good example- a recent study found that about 30% of recent journal articles were ghost-written. Translation: some drug company or other third party approached a doctor with data about one of their products and offered an honorarium if they'd put their name on it and publish it.

@ "And here I thought he was arguing about the impact of an economic issue on health care, the latter of which is a legitimate issue for the journal to be concerned with."

And yet it was published in Ann In Med rather than a public health journal or somesuch. Huh. Stuff like that always makes one wonder. (Trained to be critical- remember?) It's kind of like when a laparoscopy paper gets published in the Journal of Endoscopic Treatment rather than JACS- it's just not quite right...

"I don't know, Dean. Do you have any idea? Seriously. Ideally, they would be assembled from international sources, the WHO perhaps, but I'd speculate that in this case they were probably from the US. But even if the supply was limited, how does that impugn their expertise?"

Well, if we're being serious, I'd guess they were Americans, yes. But I think that you are clearly misinterpreting the word "expertise" on this one, Tom. That probably sounds harsh but I'm really not trying to be snide- please listen. Actually, if he used the word "expert" your friend misled you a bit- there is far too much stuff submitted for publication to get the true experts to review it all. On obscure subjects you can usually only produce reviewers who are competent at data analysis, but not experts in the field. One gets to be a reviewer slowly. You publish a few things in a journal yourself. Then that journal asks if you'd like to review someone else's paper, and if so they send you a minor work of little import, and they examine your critiques. Most critiques involve study design or data analysis- that's where a reviewer can shine. (And Barry's paper, frankly, has almost none of either.) For instance, if the reviewer points out that the statistical test used wasn't a valid one for the question asked that pretty much sends the author back to the drawing board. The best critiques involve hard points like that. (As I said, a lot of sloppiness gets sneaked through in the conclusions section, which is more subjective. That's why it is important to review the data presented and not just read the conclusions.) If you produce good critiques the journal starts sending you more important papers to review. "Important" meaning more data-heavy, analytical, and on a timely subject and thus likely to change practice. The editor himself has finite time to go through all of this- unless the paper is important, often reviewer comments are just forwarded to an author to be addressed before re-submission.

Being a reviewer does NOT necessarily mean that you are an Expert on the paper's subject, though you can be, especially if the paper is capital-I Important. For instance, if some paper claimed to overturn the nonoperative management of solid viscus injuries they might well ask Maddox to be a reviewer. There are certainly enough bariatric surgeons out there that they can always have them critiquing articles on that subject, but even then unless the article is very important it probably won't include one of the dozen or so true national bariatric gurus. There are simply too many papers submitted. Hell, I've both published and given presentations at conferences, and believe me I am no particular expert on any of those subjects!

But Barry's paper DEFINITELY qualifies as one of those "low import" papers on which new reviewers cut their teeth. I mean- there really isn't much in it to review- he just cites some other sources and discusses what they say, and presents some "conclusions." (And, yes, the scare quotes are intentional.) These conclusions are rather subjective- it's not like saying 12% died on antibiotic A and 42% died on antibiotic B, so A must be better. There's no hard data or analysis there. In essence, it's an opinion paper- what we call class 4 or 5 data. See:

http://en.wikiversity.org/wiki/Types_of_Evidence_in_Medicine

For instance, when you read a Cochrane review they always specify what class of evidence their recommendations are based upon. (This is a 5-point scale, with 1 being the best and 5 the worst evidence.) Now, sometimes bad evidence is the only evidence you have, but you should still keeps it's quality in mind. An opinion paper by Maddox probably carries a lot of weight, without better evidence to the contrary. (I admit ignorance as to Barry's standing in this field.)

Just as in the media, journals occasionally re-visit issues, and I think this paper is an example of that. "Well, it's about time we made it clear that we don't support the Cuban embargo again, eh, fellows?"

And, yes, I'll go out on a limb and suppose that no one who reviews for Ann In Med is going to be terribly familiar with the effects of the Cuban embargo. Papers like this get published for the same reason that papers about war wounds get published in surgical journals- even though high explosive injuries aren't really applicable to civilian practice they are interesting and different, and a nice break from the glut of the usual stuff. Oddly, this means that the reviews tend to be a bit less rigorous, since they want to publish them, for the sake of interest.

Whew! Well, I'll calm down a bit now. (The subject of critiquing journal articles always gets me going.) I'm not trying to be totally dismissive of the Barry paper- it is certainly a brick in your argument. I'm really just trying to say that you shouldn't hang your hat on it to the degree that you seem to be. It isn't gospel. And, in fact, it's a poor argument. An argument, yes, but far from your strongest. Honest- it's a fluff piece. IMO your best argument is the one about residual or continuing effects from when the embargo was much more strict. But, as I mentioned, we need to look at something from economic sources to decide if that's valid. From an admittedly layman's perspective I would propose that if Cuba didn't have mandated asinine economic practices they would have recovered since those stricter versions were stopped. Saying that the embargo "forced" Cuba to adopt the Soviets' bankrupt economic system sounds like another weak argument. They chose that economic system. They could liberalize today, and their recovery would be swift, even with the current embargo in place. They could have liberalized any time in the past fifty years.

Now, what would REALLY be fun would be to switch sides in this debate and see what we could each produce!

Edited by acrosome on 03/07/2013 09:47:32 MST.

Nice thread drift, once again. I know nothing about the realities of the Cuban embargo. I know too much about the peer review process, and agree with Dean on this one, I'll take it one step further and add that a large proportion of articles submitted for potential publication get rejected, so you never even read about the research. Often this rejection is due to poor study design or interpretation, but just as often it is because the research doesn't 'jive' with the reviewers world view, or because it is what we call a 'negative' study. In other words, if someone submitted a paper which concluded the embargo had no impact on health care in Cuba, it may be less likely to get published merely because it is boring to read about studies that don' show anything exciting. There are powerful biases at all levels of the peer-review process, to the extent that what is published is not necessarily the truth, the whole truth, and nothing but the truth.

"I've discovered that when a layman tries to cite a medical article, it's usually a BAD one. Kind of like how bad money drives out good, or something. A great example was that one paper about vaccines and autism from Lancet, which was horrible. The authors retracted and disavowed it (after the lead author was found guilty of misconduct), the editor admitted it never should have gotten published, etc., yet it is still cited on all the wingnut websites."

Are you arguing that because I'm a layman every medical article that I cite is a bad one? I've cited a fair number of them, all coming to pretty much the same conclusion. Are they all bad? If so, where are your countervailing good sources to support your argument?


"But I'll grant you this- I've been taught to be very critical of journal articles, so perhaps my suspicious nature colors my outlook. My residency program hit that subject pretty hard. If you're going to be practicing medicine you've got to be able to spot BS. I am definitely capable of going through a paper and deciding if it's a "good" one or not. And, yes, there are a lot of "not good" ones out there. That's the simple truth. I will also grant you this: Ann In Med is a higher-end journal, so probably less garbage, but also certainly not garbage-free."

In one sense, your training has taken this discussion to a higher level, at least as far as concerns me, by forcing me to choose my sources with extra care, knowing I shall have to defend them against a formidable opponent. On the other hand, your self described ability to decide which articles are "good" and which are "not good" troubles me, especially when the subject at hand is one outside of your field of expertise, as you freely admit. I am relieved that you consider Ann In Med to be a higher end journal, which should make articles published by it at least admissible in support of my position.

"A good example- a recent study found that about 30% of recent journal articles were ghost-written. Translation: some drug company or other third party approached a doctor with data about one of their products and offered an honorarium if they'd put their name on it and publish it."

How does that concern our discussion? Do you think the Cuban Government paid some of my sources to write these articles, and the journals cited to publish them? ;0)

"And yet it was published in Ann In Med rather than a public health journal or somesuch. Huh. Stuff like that always makes one wonder. (Trained to be critical- remember?) "

OK, then lets go back to a source I initially cited, which you have ignored so far in this discussion, The American Journal of Public Health. My original citation linked to an abstract, but I will link to the complete article here for your convenience. It seems to this layman to be well written and copiously references a variety of sources, including The New England Journal of Medicine, The WHO, AJPH, Lancet, and a host of others. I will be interested to know your opinion about its contents, as well as whether or not it falls in the garbage category. If it passes muster, I think you will have to admit that it pretty well nails down the connection between the embargo and Cuba's deteriorating health care and nutrition situation in the early 90's, with results which far outlast the date when the embargo restrictions were loosened.

Edited to include link to full article. Another senior moment. Sorry to keep you in suspense, Dean. ;)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380757/pdf/amjph00500-0017.pdf

"Well, if we're being serious, I'd guess they were Americans, yes. But I think that you are clearly misinterpreting the word "expertise" on this one, Tom. That probably sounds harsh but I'm really not trying to be snide- please listen. Actually, if he used the word "expert" your friend misled you a bit- there is far too much stuff submitted for publication to get the true experts to review it all. On obscure subjects you can usually only produce reviewers who are competent at data analysis, but not experts in the field. One gets to be a reviewer slowly. You publish a few things in a journal yourself. Then that journal asks if you'd like to review someone else's paper, and if so they send you a minor work of little import, and they examine your critiques. Most critiques involve study design or data analysis- that's where a reviewer can shine. (And Barry's paper, frankly, has almost none of either.) For instance, if the reviewer points out that the statistical test used wasn't a valid one for the question asked that pretty much sends the author back to the drawing board. The best critiques involve hard points like that. (As I said, a lot of sloppiness gets sneaked through in the conclusions section, which is more subjective. That's why it is important to review the data presented and not just read the conclusions.) If you produce good critiques the journal starts sending you more important papers to review. "Important" meaning more data-heavy, analytical, and on a timely subject and thus likely to change practice. The editor himself has finite time to go through all of this- unless the paper is important, often reviewer comments are just forwarded to an author to be addressed before re-submission.

Being a reviewer does NOT necessarily mean that you are an Expert on the paper's subject, though you can be, especially if the paper is capital-I Important. For instance, if some paper claimed to overturn the nonoperative management of solid viscus injuries they might well ask Maddox to be a reviewer. There are certainly enough bariatric surgeons out there that they can always have them critiquing articles on that subject, but even then unless the article is very important it probably won't include one of the dozen or so true national bariatric gurus. There are simply too many papers submitted. Hell, I've both published and given presentations at conferences, and believe me I am no particular expert on any of those subjects!"



But Barry's paper DEFINITELY qualifies as one of those "low import" papers on which new reviewers cut their teeth. I mean- there really isn't much in it to review- he just cites some other sources and discusses what they say, and presents some "conclusions." (And, yes, the scare quotes are intentional.) These conclusions are rather subjective- it's not like saying 12% died on antibiotic A and 42% died on antibiotic B, so A must be better. There's no hard data or analysis there. In essence, it's an opinion paper- what we call class 4 or 5 data. See:

http://en.wikiversity.org/wiki/Types_of_Evidence_in_Medicine

For instance, when you read a Cochrane review they always specify what class of evidence their recommendations are based upon. (This is a 5-point scale, with 1 being the best and 5 the worst evidence.) Now, sometimes bad evidence is the only evidence you have, but you should still keeps it's quality in mind. An opinion paper by Maddox probably carries a lot of weight, without better evidence to the contrary. (I admit ignorance as to Barry's standing in this field.)"

I don't dispute any of this as a general description of the shortcomings of the peer review system, even though it is the best thing we have going at present. How could I, as a layman? Still, you haven't shown me any hard data to support your characterization of the Barry article as flawed, and both its data sources and reviewers as being of dubious quality, other than to say that data from Cuban sources is, ipso facto, flawed.
Were someone to write an article about child malnutrition in the US, citing US sources, be similarly flawed, or is US data, by definition, valid? Just curious. Or would this be just another example of American Exceptionalism? ;0)

"Just as in the media, journals occasionally re-visit issues, and I think this paper is an example of that. "Well, it's about time we made it clear that we don't support the Cuban embargo again, eh, fellows?""

I seem to recall you telling me several posts ago that the article could not be construed in any way as reflecting the opinion of the editors of Ann In Med. Have you had a change of heart. ;0)

"And, yes, I'll go out on a limb and suppose that no one who reviews for Ann In Med is going to be terribly familiar with the effects of the Cuban embargo. Papers like this get published for the same reason that papers about war wounds get published in surgical journals- even though high explosive injuries aren't really applicable to civilian practice they are interesting and different, and a nice break from the glut of the usual stuff. Oddly, this means that the reviews tend to be a bit less rigorous, since they want to publish them, for the sake of interest."

That does seem to be going out on a limb a bit, in the absence of supporting evidence.

Off on a tangent, given the increasing incidence violence in this country and the ever more powerful weaponry employed by both the bad guys and the good guys, I should think that the knowledge of how to treat war wounds would be of more than passing interest to trauma surgeons here in the US.

"Whew! Well, I'll calm down a bit now. (The subject of critiquing journal articles always gets me going.) I'm not trying to be totally dismissive of the Barry paper- it is certainly a brick in your argument. I'm really just trying to say that you shouldn't hang your hat on it to the degree that you seem to be. It isn't gospel. And, in fact, it's a poor argument. An argument, yes, but far from your strongest. Honest- it's a fluff piece."

It appears to me to be more a case of you trying to hang my hat on it. If it were the only article I had cited reaching the same conclusion, I would have to agree with you, especially given that I would be presenting it to a medical professional like you. However, I have cited 2 articles from medical journals, one from Amnesty International, one from a Cuban who lived thru the embargo from its beginning up until 2002, one from the president of the EU, one reflecting the near unanimous opinion of the UN General Assembly, including all of our NATO allies and the Scandinavian countries, practically every nation on earth excepting our toady buddies in Israel, Palau and Micronesia, and two abstentions also from the Pacific Island group. In other words, there is near unanimity among the nations of the world. But, just for the heck of it, I'll add 3 more medical sources on PubMed, from a list of 8 hits I got with a layman's simplistic search argument of (Cuban embargo) AND (health care):

http://www.ncbi.nlm.nih.gov/pubmed/9648115

http://www.ncbi.nlm.nih.gov/pubmed/8942780

http://www.ncbi.nlm.nih.gov/pubmed/7798873

"IMO your best argument is the one about residual or continuing effects from when the embargo was much more strict. But, as I mentioned, we need to look at something from economic sources to decide if that's valid. From an admittedly layman's perspective I would propose that if Cuba didn't have mandated asinine economic practices they would have recovered since those stricter versions were stopped."

As I think we have agreed, part of the fault lies with Cuban economic policies. That said, it is nigh impossible to turn an economy around on a dime, especially when the leaders of a country perceive themselves under siege by a superior power bent on their destruction waiting to exploit the disruption. Remember, they had to slowly and painfully convert to the Soviet system of industrial standards for all the bits and pieces of industry, etc, and would have had to reconvert if they were to integrate with the Western economies. It could be done, and doubtless was being done piecemeal as more and more Western nations decided to defy the US and trade with Cuba, but to turn things around completely would take far longer. Then there is the human reality that positions had hardened on both sides, and not all decisions were being made rationally. Speaking of asinine positions, you could as well argue that we should have turned on a dime and dropped the embargo. Had both sides dropped their asinine positions, I have no doubt the Cuban people would be far better off today than they are, and we would have a slightly lower unemployment rate and far stronger moral standing in the eyes of the world.

"Saying that the embargo "forced" Cuba to adopt the Soviets' bankrupt economic system sounds like another weak argument. They chose that economic system."

Given our attempts to strangle their revolution in the crib, what other choice did they have? The Soviets were the only supporter with the muscle to give us pause, and had a system that was viewed at the time by many less developed nations as offering a credible economic alternative to Western style democratic capitalism in parts of the world where issues of economic justice were far more important than freedom of speech, the right to bear arms, and democracy as a system of government. There simply was no other practical alternative. Keep in mind that the fatal flaws in the Soviet system were yet to be laid bare, and by the time they were, the transition to their model was complete.

"They could liberalize today, and their recovery would be swift, even with the current embargo in place. They could have liberalized any time in the past fifty years."

They are liberalizing today, slowly to be sure, given their well founded suspicions about our intentions, but liberalizing nonetheless. As to whether or not they could have liberalized anytime in the past 50 years, well that is highly debatable. We have discussed that subject peripherally here, but to really get into it would require starting another thread, IMO. It is at heart a geopolitical question where economics and health care would play a supporting role instead of being the center of attention, as they have been here.

"Now, what would REALLY be fun would be to switch sides in this debate and see what we could each produce!"

Your setting me up, Dean. Where would I find any sources to support my new position? ;0)

Edited by ouzel on 03/08/2013 09:36:43 MST.

" but just as often it is because the research doesn't 'jive' with the reviewers world view,"

In which case it would be reasonable to assume that if an article IS published, it would likely reflect the reviewer's world view, or at least not offend it? Thinking back to the Barry article published in Ann In Med.

"or because it is what we call a 'negative' study. In other words, if someone submitted a paper which concluded the embargo had no impact on health care in Cuba, it may be less likely to get published merely because it is boring to read about studies that don' show anything exciting."

Even on a subject as controversial in the US as the Cuban embargo? Surely there must be something out there? One teeny weeny little article? Where are the Cuban expats and the various other assorted right wing nutters and Ayn Rand acolytes, including at least a few docs willing to defend the embargo against all those godless Comm-symps over at Ann In Med and the AJPH? The silence has so far been deafening.

"Now, should I boycott BSA

or

undermine their ranks and subvert them with my heathen, godless, ### passion for the outdoors!"

I don't agree with their stance on the exclusion of homosexuals and I'm happy to hear that they are readdressing the issue. While there has always been a spiritual foundation to the BSA, I have no memories of it being oppressive or in my face. I went backpacking with people of all faiths and backgrounds (some of who were de facto agnostic or atheist) and I can't remember it every becoming an issue.

I don't see anything to be gained by trying to subvert the BSA from the inside. The boys are not the guilty parties and don't need that kind of drama. I see this in a similar vein to if I choose to send my kids to a Lutheran camp, I should expect that they will be exposed to Lutheran dogma.

FWIW my new favorite hobby is to read the first and last pages of these lengthy threads and let my imagination resolve what happened in between!

Edited by IDBLOOM on 03/08/2013 09:08:23 MST.

OK, now we're just getting irritable...

I'm replying very quickly, before my PM clinic starts, so please forgive my bruskness- I haven't had time for my usual re-re-re-editing...

@ "Are you arguing that because I'm a layman every medical article that I cite is a bad one? etc, etc."

No. That was sort of an aside. Step back from the ledge, Tom. For all I know you are NOT a layman, after all. I have no idea what you do.

I was just trying to point out as a general observation that a lot of laymen put great stock in something simply because it was published in a medical journal, and that they shouldn't. There's quite a bit of useless crap in the journals.

I can see how that might have been easily misinterpreted, though. My bad.

@ "On the other hand, your self described ability to decide which articles are "good" and which are "not good" troubles me,..."

Why on earth would that "trouble" you? It's MY JOB. You're sounding rather alarmist here, Tom. Sorry- I'll call that one like I see it. I assume that's just poetic license on your part or something. But there is a lot of garbage, not to mention CONFLICTING data out there, and part of my job is to pluck the wheat from the dross. If that upsets you, well, then that upsets you. I'm sorry.

Yes, this is outside my area of expertise. (As it is outside of yours.) But I am capable of critiquing the basics of a paper. I can tell you if a given statistical test was appropriate, for instance, and I can tell you if something stated in conclusions wasn't even addressed by the data presented.

For instance...

@ "OK, then lets go back to a source I initially cited, which you have ignored so far in this discussion, The American Journal of Public Health...."

OK, lets.

First- it's from 1997! You are again complaining about an embargo that no longer exists. But, whatever, I'll let that slide.

Second, and more to the point, that paper does not say what you seem to think it says. Actually, maybe it DOES say what you think it says, but it shouldn't. They again include statements in their conclusion section that are not supported by their data. That paper is a long analysis of just how degraded the Cuban healthcare system is becoming. In fact, it seems to do a decent job of listing those issues- but I haven't checked their sources to comment on how accurate they are. But that's not the issue. In their conclusions the authors do blame this on the embargo, yet they presented absolutely no evidence to back that up. They seem to assume it as a given. Well, actually, they didn't label it "conclusions", they called it "discussion", which I guess is more forgivable. But my critique stands. Stuff like that gets past reviewers all the time.

You are presenting these medical journal articles as arguments that the embargo is killing Cuban healthcare, and they patently are NOT such evidence. They are evidence that Cuban healthcare is withering, yes, but give no weight to the argument that the embargo is causing this. Most of them ASSUME that the embargo is causing this, and they so state, but none even TRY to present anything to prove that. Which isn't really shocking, since these are MEDICAL journals.

Ugh, clinic. More later...

EDIT- Actually, I read that paper rather quickly. Give me a bit more time to go through it...

By the way, those three abstracts you cite were all from the 90s, too. And abstracts aren't helpful- give me links to full articles, because if you aren't willing to read your own sources I'm certainly not going to do so.

But, honestly, you're moving me on just how bad the 90s were, after the loss of Soviet aid. It's all still mostly the fault of screwed up Cuban economics, mind you, but if all the NGOs were complaining that loudly about how onerous the requirements were that prevented them from protecting the Cubans from themselves then there probably was something to it. And, since everyone complained about the onerous paperwork needed to ship humanitarian aid to Cuba- tada!- the US loosed restrictions in 2000 (and even more later in 2009). A decade of delay probably was reprehensible, but they did it. So, where are all the papers about the Cuban embargo that post-date 2000? None? Perhaps because the issue is now moot?

@ " Speaking of asinine positions, you could as well argue that we should have turned on a dime and dropped the embargo."

Well, as I'm trying to point out, we sort of did. Not on a dime, true, but we greatly eased restrictions in 2000. Arguing that the US should have just dropped the embargo is pointless- I agree with you on this root point, remember?

@ "Had both sides dropped their asinine positions, I have no doubt the Cuban people would be far better off today than they are, and we would have a slightly lower unemployment rate and far stronger moral standing in the eyes of the world."

I'll certainly agree with you, there. And if one of the "asinine positions" you're referencing is a command economy I'd propose that improvements in Cuba would be profound.

EDIT-

Ok, I've re-read the Am J Pub Health article in greater detail and my critique mostly stands. It proves that healthcare in Cuba was on the skids in 1997. It does not prove that this was caused by the embargo. The authors ASSUME that it was caused by the embargo, and even rather disingenuously title some sections things like "The Embargo's Effect on Nutrition." But those sections present nothing to prove that the embargo is to blame.

The penultimate section actually is a quite good one, though. It at least presents some numbers showing that after the 1992 restrictions that healthcare imports dropped significantly. They are still left with the issue that correlation does not prove causation... but it sure hints strongly, doesn't it? They also better argue that US companies dominate certain healthcare sectors. But was the drop in imports due to the embargo, or because without Soviet aid they couldn't afford it? The authors claim that Cuba applied for licenses to import far more medical supplies from 1992-95 than they were granted, but I didn't see a reference cited for this critical point. Probably just an oversight, but an annoying one, and at least mildly suspect if it came from Cuban sources. If you don't understand why Cuban sources are suspect, I weep for you. :) I also have to wonder if licenses were denied because funds couldn't be produced or something. I'm not sure how that works.

But, as I said, you've moved me on the subject of the 1990s. I'll mail you my sword. Nonetheless, that's still old news. Those issues have been corrected since 2000- there are now essentially NO roadblocks to the importation of medical or agricultural supplies. The root fact remains that Cuba's insane economic policies have rendered it incapable of recovering from the withdrawal of Soviet aid. Really, Cuba was a welfare nation throughout the Cold War- it could not exist economically without Soviet aid. When the aid disappeared the Cuban GDP dropped by 35%, for the love of God! That is not a viable economy.

@ "Still, you haven't shown me any hard data to support your characterization of the Barry article as flawed, and both its data sources and reviewers as being of dubious quality, other than to say that data from Cuban sources is, ipso facto, flawed.
Were someone to write an article about child malnutrition in the US, citing US sources, be similarly flawed, or is US data, by definition, valid? Just curious. Or would this be just another example of American Exceptionalism? ;0)"

Barry's paper is poor because it lacks substance. There's no there there. He states a conclusion not supported by the data presented. I've explained this. And trusting official American data has nothing to do with American Exceptionalism. It's merely NOT knee-jerk American self-loathing. Ahem. :) But I'm still critical of official American data, too.

It's also looking like Barry's paper was basically a very poor plaigiar- Er- well, let's say that it "heavily cited" the Am J Pub Health paper. He basically just added a few of his personal anecdotes, and condensed some information. You should stop trumpeting Barry and stick to Garfield. At least the info on import rates is cogent. Barry didn't even try. No kidding- the Barry paper sucks. You can believe me or not, at this point. I really don't care.

To summarize-

I'm now willing to grant that the effects of the 1992 reforms were probably greater than I'd thought- most especially since the Cuban economy was simultaneously imploding from withdrawal of Soviet aid.

Nonetheless, I remain convinced that since the 2000 reforms the true issue is simply that the Cuban economy is bankrupt. If they are still having a humanitarian crisis since 2000 (which I don't know, honestly) it is impossible to blame that on the embargo. I challenge you to show me a post-2000-reform paper that proves otherwise. Because we're talking about NOW, not 1997 (a point on which I've let you slide for too long) and NOW the Cubans simply can't afford it.

Ergo, NOW (i.e. not 1997) the issue is how much the embargo is strangling the Cuban economy. I propose that it does not do so to a very great degree, for reasons that I have already shown.

So, if the embargo doesn't DO much, we should end it. It makes us look bad, and gives the Castro regime a boogeyman to blame. Go in with our checkbooks blazing.

Edited by acrosome on 03/08/2013 16:43:57 MST.

OK, now we're just getting irritable..."


I apologize if I have upset you. Me, I'm thoroughly enjoying the exchange, which is hard to convey via the Internet without seeming really crude. Smiley faces and winky faces are no substitute for face to face communication, with all its nuances.

"No. That was sort of an aside. Step back from the ledge, Tom."

See above. Wish I could find a way to articulate a mischievous twinkle in the eye.

"For all I know you are NOT a layman, after all."

WOW!!! I must be faking it really good.

" I have no idea what you do."

Retired from database/data comunication system performance analysis and tuning.


"I was just trying to point out as a general observation that a lot of laymen put great stock in something simply because it was published in a medical journal, and that they shouldn't."

I figured as much. Seriously, I was just trying to get your goat a little. Like I said earlier, the Lord ain't finished with me yet. :)

"There's quite a bit of useless crap in the journals."

I am starting to move in your direction on this. As a matter of principle and innate suspicion of my own, that is why I never cite just one source when trying to make a point, although I admit to having more faith in peer reviewed journals that is perhaps warranted. It seems nothing is sacred. My faith in science is shaken. :(

"I can see how that might have been easily misinterpreted, though. My bad."

Absolutely no offense taken.

"Why on earth would that "trouble" you? It's MY JOB. You're sounding rather alarmist here, Tom. Sorry- I'll call that one like I see it. I assume that's just poetic license on your part or something. But there is a lot of garbage, not to mention CONFLICTING data out there, and part of my job is to pluck the wheat from the dross. If that upsets you, well, then that upsets you. I'm sorry."

I was just trying to make the point that perhaps when a subject is out of your field, maybe the capacity is diminished, and with it the certainty. That said, it is not a major issue for me.

"OK, lets.

First- it's from 1997! You are again complaining about an embargo that no longer exists. But, whatever, I'll let that slide."

Hopefully, because my point all along has been that the damage done in two critical periods, the early 60's and the early-mid 90's, has had effects that have lasted to the present. Sort of like if you knee cap somebody, he's going to limp for a long time thereafter. I could make a similar case for infants/kids who were malnourished and deprived of adequate health care in the early 90's being cognitively and/or physically impaired for the rest of their lives

"By the way, those three abstracts you cite were all from the 90s, too. And abstracts aren't helpful- give me links to full articles, because if you aren't willing to read your own sources I'm certainly not going to do so."

The abstracts were the only things I could get. No free articles. Nonetheless, I think they give a pretty good summary of the authors' premise(s). Also, if you look at any of these abstracts, there are numerous related citations, all making the same point, from presumably reputable sources, e.g. Lancet, Journal of the Florida Medical Association, Neuroepidemiology(from which I have copied the abstract, below), American Public Health Association, American Association of World Health, the latter two cited in the abstract I copied verbatim, below. In this regard, I assume you have done your due diligence, but have yet to see you cite even a single medical source disputing the conclusions reached by the sources I have cited. Surely, there must be something out there? Or maybe these guys are onto something?
They can't all be wrong, can they? Even given the garbage factor in medical journals.

Here's the link to the Neuroepidemiology abstract. Maybe you, as a medical professional, can access the full article.

http://www.ncbi.nlm.nih.gov/pubmed/9648115

'In 1992, the USA embargo on Cuba was tightened through the passage of the Cuban Democracy Act (CDA) that explicitly restricts food and medical supplies. The embargo has contributed to cause a number of public health problems in Cuba including: (1) an epidemic of more than 50,000 cases of optic and peripheral neuropathies in 1992-1993, resulting from dietary deficiency; (2) an epidemic of esophageal stenoses in toddlers who inadvertently drank liquid lye as a result of a soap shortage for which liquid lye was substituted; (3) an outbreak of Guillain-Barré syndrome in Havana, in June and July 1994, resulting from water contamination due to lack of chemicals for water treatment to eliminate Campylobacter sp.; (4) outbreaks of self-inflicted disease and injuries caused by rioting among Cubans detained at the US Naval base at Guantánamo Bay, and (5) a decline in medical practice standards and public health indicators in Cuba resulting from the enactment of the CDA, documented by the American Public Health Association in 1993 and confirmed in March 1997 by the American Association for World Health. Despite this evidence, the Cuban embargo remains a politically sensitive subject in the USA, resistant to public health concerns, as evidenced by the recent passage of the Helms-Burton Act. The public health effects of the CDA need to be reviewed with possible revocation or at least modification.'


"Ok, I've re-read the Am J Pub Health article in greater detail and my critique mostly stands. It proves that healthcare in Cuba was on the skids in 1997. It does not prove that this was caused by the embargo. The authors ASSUME that it was caused by the embargo, and even rather disingenuously title some sections things like "The Embargo's Effect on Nutrition." But those sections present nothing to prove that the embargo is to blame.

The penultimate section actually is a decent one, though. It at least presents some numbers showing that after the 1992 restrictions that healthcare imports dropped significantly. They are still left with the issue that correlation does not prove causation... but it sure hints strongly, doesn't it? They also better argue that US companies dominate certain healthcare sectors. But was the drop in imports due to the embargo, or because without Soviet aid they couldn't afford it? The authors claim that Cuba applied for licenses to import far more medical supplies from 1992-95 than they were granted, but I didn't see a reference cited for this critical point. Probably just an oversight, but an annoying one, and at least mildly suspect if it came from Cuban sources. If you don't understand why Cuban sources are suspect, I weep for you. :)"

True, correlation does not prove causation but the association is overwhelmingly strong, given the dominant position of the US. The "Effects of the CDA" section, BTW, applied to both food and medical imports unless I have misunderstood what they were saying, always a possibility. I'll leave you to draw your own conclusions on this one. Things like the export licenses granted by State, increased shipping fees that inflated the costs to Cuba by 400%, etc, are matters of public record, so I'm not overly surprised they neglected to cite their sources. Still, I can see how the scientist in you might be annoyed. That kind of data would come from US government sources, by Freedom of Information Act request if necessary, or publicly available commercial sources for shipping costs, not Cuba.

"But, as I said, you've moved me on the subject of the 1990s. I'll mail you my sword. Nonetheless, that's still old news. Those issues have been corrected since 2000- there are now essentially NO roadblocks to the importation of medical or agricultural supplies. The root fact remains that Cuba's insane economic policies have rendered it incapable of recovering from the withdrawal of Soviet aid. Really, Cuba was a welfare nation throughout the Cold War- it could not exist economically without Soviet aid. When the aid disappeared the Cuban GDP dropped by 35%, for the love of God! That is not a viable economy."

We're rehashing a past discussion here, and have already partially agreed. Our points of disagreement are also clear, so I'll not repeat myself . My point is that Cuba's problems are partly embargo, partly being forced in the 60's to rely on the Soviets, and partly due to their own homegrown mistakes. You've admitted that the embargo had an impact in the 90's, so we've pretty much narrowed our disagreement down to a question of how much past policies continue to affect Cuba today and the early effects of the embargo, i.e. industrial disruption, driving Cuba to the Soviets, etc. . And, hopefully, had a good time in the process. BTW, have you ever seen the movie "The Duelists", with Harvey Keitel? Hang onto your sword; you're going to need it. :)

"Barry's paper is poor because it lacks substance. There's no there there. He states a conclusion not supported by the data presented. I've explained this. And trusting official American data has nothing to do with American Exceptionalism. It's merely NOT knee-jerk American self-loathing. Ahem. :) But I'm still critical of official American data, too."

The Barry article has become a distraction, so I'll concede the point. I just wish I could have had access to the articles whose abstracts I cited on PubMed to replace him with. Ah, well. Like yourself, I am suspicious of a lot of what comes out of the US Government, but that is a long way from knee jerk American self loathing. I would like nothing more than to see my country conduct itself abroad, and at home for that matter, in a way that would make me proud again. Why I feel that way would probably take at least a couple of threads, but suffice it to say for now that it is grounded in an academic background that has nothing to do with computers, years spent overseas observing the impact of misguided policies, and even more years here watching our society crumble from within, due to other misguided policies, to the point where I am beginning to fear for the future of the Great American Experiment. I am sad, yes, but not self loathing on behalf of either myself or my country. Rather, I am sad for what we have lost, and the suffering it has brought to so many innocent people, both here and abroad.

"To summarize-

I'm now willing to grant that the effects of the 1992 reforms were probably greater than I'd thought- most especially since the Cuban economy was simultaneously imploding from withdrawal of Soviet aid.

Nonetheless, I remain convinced that since the 2000 reforms the true issue is simply that the Cuban economy is bankrupt. If they are still having a humanitarian crisis since 2000 (which I don't know, honestly) it is impossible to blame that on the embargo. I challenge you to show me a post-2000-reform paper that proves otherwise. Because we're talking about NOW, not 1997 (a point on which I've let you slide for too long) and NOW the Cubans simply can't afford it."

As I said, above, we have narrowed our differences considerably. The main outstanding one that I see is that you underestimate the impact of the past on the present, IMO, and I can't see us coming to an agreement on that one, no mater how long we argue.

"Ergo, NOW (i.e. not 1997) the issue is how much the embargo is strangling the Cuban economy. I propose that it does not do so to a very great degree, for reasons that I have already shown."

Not strangling, but certainly not making things any easier for them, and giving us a very bad name in the process, as the UN GA votes indicate. Also, we still insist that the Cubans pay cash instead of allowing export credit guarantees as we do with normal trading partners. That cuts into trade considerably, as they are very short of foreign exchange.

"So, if the embargo doesn't DO much, we should end it. It makes us look bad, and gives the Castro regime a boogeyman to blame. Go in with our checkbooks blazing."

On this, we are in accord, but without trying to force them to adopt our economic system as a precondition. Let them evolve at their own pace and in their own way, and count on broad, unconditional engagement to persuade them of the merits of our system. Or not.

Edited by ouzel on 03/08/2013 20:15:44 MST.

@ "Hopefully, because my point all along has been that the damage done in two critical periods, the early 60's and the early-mid 90's, has had effects that have lasted to the present."

Well, I thought one of your bigger complaints about the immorality (per se) of the embargo was the way it supposedly caused a medical crisis and starvation. And, since I brought it up, I've been looking for more up to date information on those issues- i.e. since 2000. Truth is, as I suspected, there isn't much in the way of convincing condemnation of the emabrgo on those grounds. Certainly nothing like those papers you cited.

Mind you, this is a VERY early take, based on a few hours of googling, and I'm still looking, so don't hold me to it. I'll look again when I'm back at work Monday and can get on PubMed or Ovid.

So I can't find any papers similar to the ones you've cited, for post-2000. I do find a lot of magazine and newspaper articles which SEEM to imply that there is no longer some sort of humanitarian crisis. I find many that again praise the Cuban healthcare system, in fact. I found a few anecdotes about areas in which Cuban healthcare seems to trail the rest of the world, but in at least one article doctors who were interviewed blamed this on their lack of access to travel and conferences. There's also mention of a recent cholera epidemic, which seems to have been brought back from Haiti. There is quite a bit of mention of the bureaucratic mess their pharmacy system is, and that it can still be hard to find some drugs- but that can no longer be blamed on the embargo.

Hmm. So far it's seeming like complaining about the 1990s is moot...

@ "Also, if you look at any of these abstracts, there are numerous related citations, all making the same point, from presumably reputable sources,... Surely, there must be something out there? Or maybe these guys are onto something?
They can't all be wrong, can they?

Well, to be frank, all of those sources you cited reference one another. It's all the same argument. It's all the same OLD argument. Most of them in fact refer to Garfield. Show me something post-2000, or better yet post-2009.

Regarding the call for a medical publication disputing that the embargo caused a humanitarian crisis- such a "negative" paper would never get published. Plus, who would be motivated to publish it? I showed you the State Department and the US Chamber of Commerce's economic analyses, which hold a lot more weight with me ( and any rational person) than the economic opinions of Am J In Med.

And I repeat- I really have to make this point- except for the economic bit in the Garfield paper NONE of any of the medical articles you cited make any sort of case that the embargo contributed to the collapse of the Cuban medical system. Really- can you address this? You haven't, yet. They all document the failures of Cuban medical care and ASSUME that the embargo caused this, and then disingenuously try to state that in their conclusions, but none actually present any data. So you haven't really produced many medical articles that support your position, either! You've got Garlied, which is out of date by a quite a bit.

So mostly, I want you to produce something more timely. I don't think it's out there.

@ "My point is that Cuba's problems are partly embargo, partly being forced in the 60's to rely on the Soviets, and partly due to their own homegrown mistakes."

True, we've agreed on this. My point is merely that since we're talking about ending the embargo NOW we should be talking about the embargo as it exists NOW. I see (I think) three issues pertinent to our argument that affect the humanitarian situation in Cuba:

1. Any direct effects of the embargo due to limiting importation of medical supplies, etc.
2. Indirect effects of the embargo, by the degree to which it damages the Cuban economy and thus limits their ability to pay for a medical system.
3. Innate inefficiencies of the Cuban economic system NOT due to the embargo, which limits their ability to pay for a medical system.

I say that #3 is the major effector, here, post-2000 (i.e. NOW). You disagree. I can leave it at that.

@ "The main outstanding one that I see is that you underestimate the impact of the past on the present..."

That's odd, because your major failing that I've identified is that you underestimate the inefficiencies of a command economy, and the deleterious effect it is having on the Cuban medical system. :)

More seriously, I do think that you got the "the embargo is causing a humanitarian crisis in Cuba" meme rooted in your brain a couple of decades ago and aren't moving past it. So, you went looking for sources to back you up and produced those journal articles, and never even noticed that they are very dated. My State and Commerce analyses are much more recent.

I also think that you keep ignoring the effect of the withdrawal of Soviet aid. The Cuban GDP contracted 35%! Jesus- 35%! And this was also temporally associated with the crisis of the 90s. As I said, I've been moved- the tightened embargo of 1992 probably went too far. But mostly it's effect was potentiated by very unfortunate timing- imposing it just as Cuba imploded when the aid went away. They were very reliant on Soviet aid, since their economy was not otherwise viable. And that was not really a result of the embargo. And their economy continues to languish. Show me something more recent.

@ "Not strangling, but certainly not making things any easier for them, and giving us a very bad name in the process, as the UN GA votes indicate."

It's really odd to hear you say that, since that's sort of been my argument all along- that the embargo is not strangling the Cuban economy and gives us a bad name.

@ "Also, we still insist that the Cubans pay cash instead of allowing export credit guarantees as we do with normal trading partners. That cuts into trade considerably, as they are very short of foreign exchange."

Indeed, that is a requirement that we don't insist upon from others. Meh. I'm not moved. The lack of foreign exchange is entirely the Cubans' own fault, though, as the sources I've cited indicate (and a few of yours, too). It stems from very bad fiscal policy on their part, in particular refusing to allow stocks of any foreign currencies to be maintained- a policy that was eased only very recently.

Edited by acrosome on 03/09/2013 18:20:51 MST.

I said I’d look up those PubMed abstracts:

I can't find the full text of the PubMed abstract about epidemic neuropathy anywhere. I'd have to have my library send out for a copy, and I can't really do that ethically for the sake of an internet argument. :)

The Kirkpatrick article from Lancet is, again, old (1996). It’s also odd, because it mentions that the 1992 reforms exempted medical supplies, but what it really seems to attack is the Helms-Burton Act from the same year, which could not have had a lot of effect by then. It had only been passed a couple of months prior. (Political motives?) It’s basically a bunch of anecdotes- case studies, if you will, class 4 data. Frankly, the whining about the bureaucratic requirements to meet the exemption criteria still sounds like whining to me. To SOME degree at least Kirkpatrick agrees- he mentions that in a few cases Cuba did allow the required on-site inspections and that importation then went unimpeded. He calls this “an intrusion on Cuba’s sovereignty.” Pffft. It sounds like if Cuba wanted to import this stuff and had the money that they could have, by allowing the inspections. And these weren’t US government inspections, they are just checks by the exporters so that they could honestly sign an end-use certificate. Also, the article quotes a lot of “personal communication” with representatives at medical equipment companies about how hard it was to get licenses- and that’s class 5 data, Brother. The companies complained they were “unable to establish a meaningful dialog with the US Department of Commerce in a manner consistent with standard business practices”, which again sounds like whining. There was an embargo in place- practice was not going to be standard. In general, though, there are NO numbers in the entire article- no data- nothing is quantified. It is basically an editorial- which, when I think of it, is really what most of your sources are.
But, as I’ve said, I’ve been moved on just how restrictive the 1992 reforms were. I still think they are clearly less important that the baseline nonviability of the Cuban economy, though. Yes, Helms-Burton in effect made medical supplies more expensive by addind administrative costs, but how expensive could it be to send a couple of guys to Cuba to verify that a clinic the item is intended for actually exists? That’d be an issue in the US system where an independet clinic might order one spare part for a device, but presumably not in the centralized Cuban system. But most importantly- THOSE RESTRICTIONS NO LONGER EXIST.

And then your sources reveal their connection… the Kirkpatrick/Garfield paper from that giant among medical journals, the J Fla Med Assoc. Which with a title like “The time has come to lift the economic embargo against Cuba” sounds straight up like an editorial, and pre-dates the works you’ve already cited. So, probably the same arguments and data- or lack thereof. Needless to say I can’t find that full text anywhere, either- my library certainly doesn’t stock it.

Since the subject came up, here is EVERYTHING I could find on PubMed about the embargo that was published since 2000:

Int J Health Serv. 2005;35(4):797-816.
Economic crisis and access to care: Cuba's health care system since the collapse of the Soviet Union.
Nayeri K, López-Pardo CM.
SourceUniversity of California, Survey Research Center, Berkeley, CA 94720-5100, USA.

Well, it's no surprise that this travesty came out of Berkely. They mention an economic recovery around 1995. Since the embargo didn't change then, presumably this is a recovery from the withdrawal of Soviet aid. The article is based on interviews conducted in 2003, mostly Cuban government officials but also a few patients- class 4 or 5 data at best, Cuban government propaganda at worst. It does include some economic figues that in no way show that medical hardships were caused by the embargo. It's just a litany of the collapse of Cuba's economy. By 1993 Cuban GDP had dropped to 65% of it's 1989 level due to withdrawal of Soviet aid. They mention the drop in caloric intake. They show that Cuba's medical budget in 1993 was 25% of what it was in 1989- and that wasn't due to the embargo, Brother, it was simply a function of a failing economy. Etc. They mention that the recovery was incited by changed economic policies, such as legalizing possession of foreign currency, and allowing entrepreneurship and even some free markets. Then the paper just becomes a list of remarks by official Cuban sources that blame all ills on the embargo (i.e. the offical Castro regime's excuse). "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." That's not a very convincing paper.

Not to mention that it simultaneously tries to argue that as Cuba climbed out of the crisis of the early 90s that everything improved again to 1989 levels, but that the embargo nonetheless causes terrible suffering. (So, at least from my perspective of debating the emabrgo as it is NOW, this paper supports me, even using official Cuban figures.) And from what I've been reading elsewhere their conclusions about differential access to care- which seems to have been the main goal of the study- sound like utter BS. It's probably also another official position of the Castro regime. Countless other sources I've seen mention that the Cuban elite and foreign medical tourists get much better care than average Cubans. The acknowledgements mention all of the help the author got from various official Cuban government agencies. Also, one of the responses to the article is titled "Cuban health care: consider the source", and questions the proposition that ANYTHING the Cuban government says about healthcare can be believed, so clearly it isn't just me... :)

Finally, I googled the authors. The first author is a Cuban and Iranian apologist, and a little left of Vladimir Lenin. He has a website fawning over the Cuban revolution, and publishes other works for communist audiences. Both authors work for, among other institutions, the Marxist School of Sacramento. Not being fluent in Spanish I can't read most of the hits for the second author, since they seem to originate from Cuba. :) But clearly they are both communist True Believers, which explains this horrible paper.


Qual Prim Care. 2008;16(4):269-77.
The health of a nation: perspectives from Cuba's national health system.
Offredy M.
SourceUniversity of Hertfordshire, Hatfield, UK. m.v.offredy@herts.ac.uk

This article actually isn't very relevent except in that it demonstrates that there is no current healthcare crisis in Cuba. It's really a sort of overview of how the Cubans run primary care. Admittedly, they are clearly better at disease PREVENTION than almost anyone else. Most other systems focus on disease treatment, instead. We could certainly learn something from them. It does mention Helms-Burton and other aspects of the embargo but only briefly as a historical aside in the background section. (It also admits that it avoids including any comments from the AIDS patients who are segregated into sanitoria. I wonder why.) In conclusions it fawns over the Cuban primary care system and their polyclinics, though in this case the fawning might be warranted- their system of primary care is clearly an excellent one.

Science. 2010 Apr 30;328(5978):572-3. doi: 10.1126/science.1189680.
Global health. Fifty years of U.S. embargo: Cuba's health outcomes and lessons.
Drain PK, Barry M.
SourceSchool

Note- Barry is second author. The first half of the paper does again bemoan the 1990s- it is essentially a restatement of Barry's prior paper. The second half lauds the current state of Cuban healthcare (so, even Barry agrees with me about there not being much of a crisis NOW) and again fawns over their primary care system.

It does mention the 2009 US Senate report, which concluded "the unilateral embargo on Cuba has failed to achieve its purpose," with which I agree, as I have said. End the embargo because it doesn't work and gives the Castro regime a boogeyman to blame for everything.

That's it- three articles, all told. (Other than a few more epidemiologic papers about optic neuropathy, the abstract for one of which mentions that the Cuban epidemic ended in the late 90s.) One paper is clear propaganda, and two support my position that since at least 2000 there is no healthcare crisis in Cuba. Heck, even the propaganda one supports my position, it just simultaneously tries to complain about the US in any way possible.

Garfield is still by far the best source you have, and he's dated- he's a source on Cuba in the early-to-mid-90s. So, what do you think about NOW? Do you still think that the embargo is causing medical hardship in Cuba as of 2013?

Edited by acrosome on 03/11/2013 10:06:28 MDT.

I can't find the full text of the PubMed abstract about epidemic neuropathy anywhere.

See if this works (I suspect it's access-restricted):
http://www.karger.com/Article/Pdf/26161

It's a review article (i.e. summary of existing literature), rather than a primary source. Its references include the Kirkpatrick and Garfield articles. On the specific topic of epidemic neuropathy, attribution is assigned based on this article:
http://www.nejm.org/doi/full/10.1056/NEJM199511023331803

The NEJM article attributes it to a lack of nutrients (methionine, vitamin B12, riboflavin, and carotenoids) combined with tobacco use and possible cassava consumption. It suggests economic troubles around '91-'93 contributed to decreased food availability, particularly animal products. An anti-smoking campaign and vitamin supplementation program were implemented to address this.