Garfield Responds

Despite the emergence of large-scale conflict in Syria and other middle-income countries in recent years, the majority of all cross-border conflicts since the end of the cold war have occurred in low-income countries.¹ Their economic, social, and environmental vulnerability have left them exposed to health risks resulting from interrupted supply of key imports such as medicines, sanitary goods, and energy supplies. As Khanal et al. point out, Nepal is one such country, where low per capita income and literacy coupled with physical isolation and dependence has left many people dependent on imported goods from neighboring India.

Embargos against Cuba over five decades has had a very different character and impact. Cuba benefitted from greater social and economic investments, especially in the 1960s, and had reached the current level of infant mortality in Nepal in the early 1970s. Cuba, at times, was even more isolated than Nepal geographically as an island country, but a strong centralized state. A large-scale assistance from the Soviet bloc assisted Cuba to retool its economy and organization to minimize the impact of the embargo over several decades.

We might better understand the vulnerabilities that a country may face during conflict by reviewing the World Health Organization’s six building blocks of a health system.² Nepal’s health workforce and service delivery capacity are weak, but are not weakened by new limits on terrestrial imports. Now is the time to utilize the health information system, focus on access to essential medicines, and exert leadership to minimize damage. Luckily, key goods for immunization and maternal–child health can be provided via international organizations and air transport, if these other key elements are in place. At various times, Cuba has had greater threats attributable to loss of the health workforce, loss of finance, and both air and ground blockage in access to medicines.

In the short term, Nepal is more vulnerable, particularly where key goods for child survival and public health programs must be imported. Under such an external threat, countries sometimes are able to mobilize social cohesion and local resources to replace some of the goods lost because of trade interruptions. Among these are the promotion of immunization, early treatment of common diseases, breast-feeding, and the promotion of hygiene and sanitation awareness.

In the long run, health development in both Cuba and Nepal depend mainly on national commitments and, even where income is low, local resources. We may be unable to resolve the political issues that lead to conflict, but a great advantage of the public health field is that we always can identify opportunities to strengthen health systems and resilience. These can continue to serve society even after conflicts are resolved.