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Albright, Medical Journal: Contrasting Commentaries on Sanctions

An American medical journal -- "Annals of Internal Medicine" -- has just
published the following commentaries on sanctions' effect on public health.
The author of the first piece, which defends U.S. policies, is Secretary of
State Madeleine Albright.  Counterpoint is provided by the Ethics and Human
Rights Committee of the American College of Physicians-American Society of
Internal Medicine, the largest American medical specialty society.

Responses can be lodged here:

Drew Hamre
Golden Valley, MN USA

Annals of Internal Medicine


Economic Sanctions and Public Health: A View from the Department of State
Annals of Internal Medicine, 18 January 2000.

I welcome the opportunity to comment on topics raised in this issue about
the importance of minimizing the effect of economic sanctions on public
health (1, 2). The Clinton Administration fully supports this goal and seeks
a partnership with the public health community in making further progress
toward it. 

Sanctions as an Alternative to Force
Historically, sanctions have been used as a tool-short of war or other, more
extreme measures of coercion-to induce a government violating international
norms to improve its policies. Sanctions have also been used as a punishment
for such violations. In recent years, especially, sanctions have often been
supported or proposed by nongovernmental organizations concerned with such
matters as religious freedom, respect for human rights, and the apprehension
of war criminals. In the United States, this support is reflected in the
flood of sanctions-related legislation annually considered by Congress. 

Despite this, the overall record of sanctions as an instrument of policy has
been mixed. In many cases, sanctions have been imposed for years, even
decades, without achieving their objectives. However, most observers would
agree that U.N. sanctions contributed significantly to the downfall of
racist regimes in the former Rhodesia and South Africa. In this decade,
sanctions caused Libya's government to make available for trial two men
suspected of the terrorist sabotage of Pan American Flight 103. Currently,
sanctions are an important source of pressure against the regime of indicted
war criminal Slobodan Milosevic in Yugoslavia. In Burma, the democratic
opposition, led by Nobel Prize-winner Aung San Suu Kyi, strongly supports
sanctions as a way to prod that nation's repressive military toward a more
open political system. 

Mitigating the Harmful Effects of Sanctions
As a policymaker, I have long been concerned that sanctions-like force-can
be a blunt instrument. When the United Nations or the United States imposes
sanctions against a regime, whether in response to military aggression or
egregious violations of human rights, it does not intend to create
unnecessary hardships for innocent people, especially children and infants.
Good intentions, however, do not automatically translate into good results. 

In recent years, the United States has joined the United Nations and other
concerned countries in exploring ways to preserve the effectiveness of
sanctions while minimizing harm to innocent civilians. One method involves
imposing only limited sanctions by, for example, restricting visas for
government officials or prohibiting civil air transportation. A second
method of limitation was articulated by President Clinton in July 1998 when
he declared that "food and other human necessities should not be used as a
tool of foreign policy except under extraordinary circumstances." 

The president's statement builds on a long-standing record. The United
States has supported emergency food relief since at least the 1920s and has
offered support for public health, infant nutrition, child survival, and
anti-hunger projects around the globe for more than half a century. The U.S.
Agency for International Development, in particular, has been a champion of
public health in partnership with the United Nations Children's Fund
(UNICEF), the World Health Organization, and a broad array of
nongovernmental organizations. 

These policies have been sustained even when the governments of the
countries involved have been subject to sanctions. For example, over the
past decade the United States has financed more than $1 billion in food and
other humanitarian supplies that independent relief agencies have delivered
to the people of war-torn Sudan. During the past several years, the United
States has donated more than 400 000 metric tons of wheat and flour to the
World Food Program for use in North Korea. 

Adjusting United States Policy
In the same vein, President Clinton announced in April 1999 that the United
States would generally exclude food, medicines, and medical equipment from
future sanctions and that we would extend that principle to existing
sanctions where we have the discretion under U.S. law to do so. The change
does not affect Iraq, Cuba, or North Korea, where food and medicine have
always been exempt from sanctions, but it has enabled us to liberalize
regulations that govern exports to Iran, Sudan, and Libya. To maximize the
positive humanitarian effect of this policy adjustment, we are defining food
broadly as anything that can be ingested by humans and animals, including
feed and seeds. Since the adjustment has been made, U.S. companies have sold
approximately 250 000 tons of corn to Iran. 

The Case of Iraq
In recent years, much controversy has surrounded the economic sanctions
imposed by the United Nations Security Council against the government of
Iraq. These sanctions stem from Saddam Hussein's brutal and unprovoked 1991
invasion of Kuwait and his subsequent failure to comply with weapons
inspection and monitoring requirements. This failure cannot simply be
shrugged off. United Nations Security Council resolutions are designed to
ensure that Saddam Hussein does not again threaten his neighbors with
aggression or the world with weapons of mass destruction. Saddam Hussein has
used chemical weapons both in battle and against his own people. He has
started two wars. He has lied repeatedly about Iraq's weapons programs. If
sanctions were prematurely lifted and Saddam once again gained access to the
money needed to build weapons of mass destruction, we could expect him to do
so-without any moral compunction about their use. 

>From the humanitarian perspective as well as the diplomatic and security
perspectives, the case for continued sanctions as a means of pressure
against Saddam Hussein is overwhelming. There is no greater enemy to public
health in Iraq than he. At the same time, we have an obligation, which we
are meeting, to do all we can to minimize the harmful effects of sanctions
on Iraqi civilians. Even under sanctions, Baghdad has always been free to
import food and medicine. To make this easier, the United States took the
lead more than 6 years ago in proposing an "oil-for-food" program, under
which Iraq could use revenues from the sale of limited amounts of petroleum
to purchase humanitarian supplies. Saddam long resisted this plan because he
wanted to use his people's suffering to mobilize public opposition to
sanctions. During the past few years, however, the program has been
implemented and has grown steadily. The results are significant. 

During the 2.5 years that the oil-for-food program has operated, it has
delivered $3.7 billion in food, $691 million in medicine, and more than $500
million in supplies for projects involving electricity, water and
sanitation, agriculture, education, the oil industry, settlement
rehabilitation, and demining. In addition, between December 1996 and July
1999, the U.S. State Department recommended the approval of licenses for the
sale of more than $372 million in U.S. agricultural commodities for the
program. The oil-for-food program has increased the daily caloric value of
the Iraqi ration basket by 50% and has steadily improved health care. Iraq
is now importing as much food and exporting almost as much oil as it did
before the Gulf War. 

Despite all this, the humanitarian crisis in Iraq persists. The question is
why. A study issued last August by UNICEF provides strong evidence of the
answer. In northern Iraq, where Saddam Hussein's government is not in
control and the United Nations administers the oil-for-food program, child
mortality rates are now lower than they were before the Gulf War. This point
deserves emphasis: In northern Iraq, child mortality rates are lower now
with sanctions than they were without sanctions before the war. By contrast,
child mortality rates have more than doubled in southern and central Iraq,
where Saddam Hussein remains in control and the Iraqi government rather than
the United Nations administers the oil-for-food program. 

The problem is that Saddam is not using the available resources for the
intended purposes. According to the United Nations, the Iraqi government has
spent only $9.5 million of the $25 million that has been set aside for
nutrition supplies for vulnerable children, pregnant women, and nursing
mothers. Until the United Nations called attention to the situation earlier
this year, almost $300 million in medical supplies, or about half of the
supplies shipped under the oil-for-food program, was sitting undistributed
in Iraqi warehouses. In addition, while primary care needs go unmet, Baghdad
has ordered expensive diagnostic tools, such as a high-resolution magnetic
resonance imaging machine and a gamma knife (which is used in complicated
neurosurgery). There are also reports that the Iraqi regime is selling
medicines received under the oil-for-food program to private hospitals at
exorbitant prices. We also have evidence that the Iraqi military bulldozed
160 homes in the town of Almasha in June 1999 after local citizens protested
Baghdad's failure to distribute food and medicine. Meanwhile, the regime is
squandering its scarce resources on luxury cars, palaces, and resorts for
the elite. Therefore, although the oil-for-food program is giving the people
of Iraq, especially northern Iraq, access to essential food and medicine, it
would be much more effective if the Iraqi regime began to do its part. It is
Saddam Hussein's obstruction, not U.N. sanctions, that remains the primary
cause of suffering in Iraq. 

Helping the People of Cuba
Cuba is another country whose government has sought to blame sanctions for
its own failures. Unlike the sanctions against Iraq, the sanctions applied
against Cuba are unilateral, not multilateral. This means that commercial
opportunities are available to Cuba throughout the rest of the Americas,
Europe, Asia, and elsewhere. Although U.S. sanctions are indeed a source of
pressure, the fundamental problem is Havana's allegiance to economic and
political doctrines that have failed everywhere they have been tried. The
United States believes that the people of Cuba should have the same rights
as their counterparts throughout the hemisphere, including the right to have
a voice in choosing their own leaders. There would be no better route to
greater prosperity and improved public health in Cuba than a government that
was accountable to its people. 

In the meantime, the Clinton Administration has taken steps to increase
people-to-people ties between the United States and Cuba and to help the
Cuban people prepare for a democratic future. These steps include licensing
of food and agriculture sales to entities that are independent of the Cuban
government and increasing the amount of remittances that persons in the
United States can send to family members or independent organizations in
Cuba. The sale of medicines, medical supplies, and medical equipment to Cuba
is governed by the 1992 Cuban Democracy Act. Within the limits imposed by
that statute, the Department of Commerce licensed approximately $45 million
in medical sales in 1998 and the first half of 1999 and more than $100
million in humanitarian donations of medicine and medical equipment. 

The United States cares deeply about the well-being of the Cuban people.
That is why we support democratic change. To that end, we will continue to
take steps to address humanitarian needs, aid the development of civil
society, strengthen the role of nongovernmental organizations (including the
church), and otherwise help lessen popular dependence on the Cuban state. 

The United States's Commitment
Our effort to improve the effectiveness of sanctions on behalf of peace and
respect for human rights remains a work in progress. We cannot be satisfied
as long as innocent populations suffer as a result of repressive or lawless
leaders. The job of developing and revising effective sanctions is by nature
multinational, but the United States should be a leader in that effort. 

Accordingly, the Clinton Administration is committed to working with other
nations and with international and nongovernmental organizations, including
the public health community, to further explore the full range of issues
related to sanctions. We are also working with Congress on legislation for
sanctions reform that would provide the executive branch with greater
flexibility in responding to changing circumstances and new information. 

I congratulate Annals for devoting attention to a discussion of this
politically, technically, and morally complex subject. Although I wish it
were not the case, the challenge of responding to regimes that ignore
international law and run roughshod over the rights of their own people is
not likely to go away. We must continue to assess and reassess the tools we
have available to respond and to ensure that sanctions, when used, are used
in the best possible way for the best possible results. 

Madeleine K. Albright, Secretary of State 
Department of State 
Washington, DC 20520 

Requests for Reprints: Brian J. Mohler, Department of State, 2201 C Street,
NW, EB/ESC/ESP, Room 3329, Washington, DC 20520. For reprint orders in
quantities exceeding 100, please contact Barbara Hudson, Reprints
Coordinator; phone, 215-351-2657; e-mail, 

Ann Intern Med. 2000;132:155-157. Annals of Internal Medicine is published
twice monthly and copyrighted © 2000 by the American College of
Physicians-American Society of Internal Medicine. 

1. Barry M. Effect of the U.S. embargo and economic decline on health in
Cuba. Ann Intern Med. 2000;132:151-4. 

2. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights
Committee. Ann Intern Med. 2000;132:158-61. 


Annals of Internal Medicine


The Health Effects of Economic Sanctions and Embargoes: The Role of Health
Annals of Internal Medicine, 18 January 2000.

Karine Morin, LLM, and Steven H. Miles, MD, for the Ethics and Human Rights

Related Article
Related Editorial 

As a widely used tool of foreign policy, economic sanctions take many forms.
They include mandating trade restrictions (for example, limiting imports
from or exports to a sanctioned nation), freezing bank accounts, limiting
international travel to and from an area, imposing additional tariffs, and
exerting other pressures that are intended to slow key economic activities.
Since the end of the Cold War, as the global market has expanded, many
countries and the United Nations have increasingly used economic sanctions
instead of military intervention to compel nations to end civil or
extraterritorial war or to reduce abuse of human rights. Similarly, the
United States has attempted to influence international governments' domestic
policies by using other economic means, such as relating "most favored
nation" trading status to a country's human rights record or prohibiting the
import of goods from countries in which illegal child labor is widespread. 

Repercussions from these measures influence a country's economic development
and, therefore, can also affect the overall welfare of a nation's
population. In contrast to war's easily observable casualties, the
apparently nonviolent consequences of economic intervention seem like an
acceptable alternative. However, recent reports suggest that economic
sanctions can seriously harm the health of persons who live in targeted
nations. For this reason, the American College of Physicians-American
Society of Internal Medicine has undertaken this examination of physicians'
roles in addressing the health effects of economic sanctions. 

Ann Intern Med. 2000;132:158-161. Annals of Internal Medicine is published
twice monthly and copyrighted © 2000 by the American College of
Physicians-American Society of Internal Medicine. 

For the author affiliation and current address, see end of text. 

Physicians who have traveled to nations affected by comprehensive economic
sanctions report that suffering is caused by lack of medical supplies or
other basic health-related resources. In contrast, studies have found that
less comprehensive sanctions-for example, those that prohibit only
investments, exclude important trade industries, or allow delivery of
humanitarian goods and purchases through neighboring countries-are not
associated with increased mortality rates (1). Overall, it is generally
acknowledged that it can be difficult to distinguish the effects of economic
sanctions on health from the effects of war, poverty, or unjust governance
(1, 2). Nevertheless, observers' reports suggest that specific humanitarian
intervention aimed at eliminating economic sanctions could bring relief to
vulnerable populations (2-6). 

For example, although United Nations sanctions in one country excluded food
and medical supplies, the availability of basic medications decreased by 50%
because the raw materials needed to produce them could not be imported.
Consequently, rates of typhus, measles, and tuberculosis were reported to
have increased, and a 30% increase in hospital mortality rate for other
conditions and a 10% increase in the overall mortality rate were also seen

In countries against which broad economic sanctions are applied,
malnutrition caused by the high cost and shortage of food is often a leading
cause of morbidity and death among children (1, 4). For example, in four
hospitals in one targeted country, infant malnutrition was reported to
affect between 32% and 57% of hospitalized children (5). Infant malnutrition
was compounded by the unavailability of infant formula and the malnutrition
of breast-feeding mothers (5). In addition, many deaths resulted from an
increased incidence of waterborne diseases, including cholera, typhoid, and
gastroenteritis, that were caused by contaminated water and defective sewage
systems (5). According to one study team's estimate, malnutrition and
waterborne diseases led to a threefold increase in mortality rate in
children younger than 5 years of age (4). 

In another country, nutritional deficiencies were reported to have caused an
epidemic of optic and peripheral neuropathy that affected more than 50 000
persons (7, 8). Another study of the effect of embargoes on health in the
same country refers to "a significant rise in suffering-and even deaths"
caused by the unavailability of essential drugs and the inadequacy of
medical equipment (9). One observer noted that "economic sanctions are, at
their core, a war against public health" (10). 

Human Rights, Humanitarian Law, and Economic Sanctions
International human rights were articulated to protect basic human needs
(1). In addition to political and civil rights, the 1948 Universal
Declaration of Human Rights refers to a person's right to a standard of
living that allows him or her to maintain health and well-being; this
includes access to food and medical care (Article 25) (11). More recently,
in 1976, the International Covenant on Economic, Social, and Cultural Rights
proclaimed that all persons had a right to the highest attainable standard
of physical and mental health; it called on all involved countries to ensure
the prevention, treatment, and control of diseases and to create conditions
that would ensure the delivery of medical care (Articles 12.1 and 12.2)
(12). Although these responsibilities may be viewed primarily as domestic
matters, the repercussions of economic sanctions imposed by other nations
often result in a fundamental contravention of the spirit of the
International Covenant. 

International law permits parties to deviate from some provisions of human
rights treaties during war, but humanitarian law is increasingly relied upon
to protect human rights and balance military necessity with humanity (13).
The Fourth Geneva Convention of 1949 and the Additional Protocols of 1977
mandated the unhindered delivery of food and medical supplies to civilian
populations in time of war and declared that medical centers, hospitals, and
other components of the public health infrastructure that help to combat
contagious diseases and epidemics must be maintained and protected (14, 15).
It seems reasonable to expect that economic sanctions and war would operate
within similar humanitarian constraints. 

Indeed, humanitarian goods, such as food or medicine, are often exempt from
sanctions. However, this can have little practical effect if, for example,
foreign currency is not available to import such goods, foreign bank
accounts are frozen, or borders are closed (3). In addition, "virtually
unattainable" terms of trade, such as strict requirements for export
licenses or restrictions on transportation, make it difficult to deliver
food and medicine (16). 

The relation between the health of a country's population and the state of
its economy is complex and interdependent. In its 1993 report Investing in
Health, the World Bank supported the view that a healthy population leads to
economic growth; conversely, economic growth can lead to a healthier
population. Therefore, it becomes apparent that stifling the economic
lifeline of a country through sanctions curtails not only the development of
the economy but also the health of individual persons (17). Such
observations make it clear that sanctions must be closely monitored in order
to accurately assess their effect. 

Human Rights, Health, and the Ethics of Medicine
Individual physicians are professionally obliged to relieve suffering (18,
19) and to promote health. In addition, physicians and their professional
organizations must be advocates for the health of the public (19).
Clinically, this refers to promoting the highest standards of medical care
for individual patients, as stated in the Hippocratic oath. It also calls
for physicians to abjure participation in torture, as asserted in the
Declaration of Tokyo (which is endorsed by the American College of
Physicians-American Society of Internal Medicine). 

At a societal level, physicians must be wary of the tension that may exist
between government policy and the healing duty of medicine. Nazi Germany
taught us that the medical profession must diligently guard against
governments that attempt to use medicine for purposes other than healing and
caring (20, 21). Many authors consider the Nuremberg Trials, in combination
with the 1948 Universal Declaration of Human Rights, the birth of the
international human rights movement (20). 

Another important link can be seen between medicine, health, and human
rights. The health of individuals and of populations, as emphasized
respectively by medicine and public health, can encompass more than physical
and mental health and the prevention of disease, disability, and death (22).
The definition of health that was developed by the World Health Organization
refers to a "state of complete physical, mental and social well-being." In
this regard, "the promotion and protection of human rights and promotion and
protection of health are fundamentally linked" to ensure the advancement of
human well-being (22, 23). This proposition concurs with the belief that
higher socioeconomic status and better health status are related and that
the "fundamental conditions and resources to achieve health include peace,
shelter, education, food, [and] income . . ." (24). 

When we consider that the idea of human rights emerged at the end of a war
that had repercussions in all parts of the world, it is not surprising that
these rights have attained a transnational dimension. Human rights cannot be
protected solely by domestic sources, which antidemocratic governments could
repress or ignore. The international community plays an important role in
monitoring human rights abuses across borders. 

Similarly, as is most acutely illustrated by the AIDS epidemic, diseases
also know no borders. To respond more effectively to persons in need and to
preserve the health of populations, the medical profession must expand
beyond the boundaries of any given nation. To this end, some physicians may
lend their services to regions of the world that are in great need of
medical assistance. However, a true globalization of the protection of
health requires that the profession as a whole become involved in the care
of vulnerable patients. 

Taking a Stand on Economic Sanctions
The College recognizes that uncertainty accompanies any effort to modify
behavior that violates international norms of conduct. However, as a
respected voice in medicine, the College should contribute to the
development of an economics sanctions policy that minimizes the effect of
such sanctions on health. 

Controversies surrounding the application of economic sanctions cannot be
ignored or fully resolved. Economists and political observers continue to
debate the efficacy of economic sanctions in achieving policy objectives.
Although most analysts would not indiscriminately reject the idea of using
economic sanctions as an alternative to military or violent means, many have
pointed out that such sanctions are often ineffective. One study performed a
comprehensive examination of U.S. sanctions policy and found that few
sanctions could be defined as successful even when a low threshold for
success was set (25). 

It is also necessary to keep in mind that sanctions can have unforeseen or
unwanted effects. They can provoke patriotic responses against the
international community or accentuate the human rights abuses that they are
intended to minimize. Sanctions can adversely affect countries that are the
economic partners of the target country and can even harm the economy of the
country imposing the sanctions. 

It is difficult to monitor the application and effects of economic sanctions
and their unintended consequences. Therefore, the United Nations and others
have stated that clearer definitions and objectives of sanctions must be
established so that criteria to end sanctions could also be defined. There
is also great concern that humanitarian aid in general may be of little
assistance if it is intercepted and diverted from its intended destination.
To that effect, the United Nations and others have acknowledged the need to
ensure that the work of humanitarian agencies, especially health agencies,
can be pursued (26). The College further supports this idea in its

In light of the College's ethical tradition, any acknowledged reservations
and uncertainty surrounding economic sanctions do not alter physicians' duty
to reduce morbidity and mortality on a global scale. This duty underlies the
College's 1982 position on weapons of mass destruction (27). At that time,
the rationale for professional involvement in a matter that seemed more
political than medical was carefully outlined, building on the
responsibility of physicians to reduce mortality and to promote prevention.
Because of the humanistic orientation and scientific training involved in
their profession, physicians have a certain degree of social prestige that
lends credence to their intervention in the sociopolitical arena (27). Other
voices continue to reinforce this message, stating that medicine must lend
its influence and knowledge to fight forces that cause suffering, compromise
quality of life, and result in early death (28, 29). 

Former United Nations Secretary-General Boutros Boutros-Ghali challenged
that economic sanctions raise "the ethical question of whether suffering
inflicted on vulnerable groups. . . is a legitimate means of exerting
pressure on political leaders whose behavior is unlikely to be affected by
the plight of their subjects" (26). Some have argued that in order to retain
their legitimacy, sanctions must not deprive persons of their right to life
and, therefore, must not drive living conditions below those required for
subsistence (30). 

Individual physicians cannot alleviate the suffering caused by sanctions.
However, the medical and public health professions can help shape the
structure and application of economic sanctions to ensure that they protect
the health of the persons in the nations that are subject to them. 

The following recommendations to amend the structure and application of
economic sanctions continue the College's tradition of addressing such
issues. With the assistance of other organizations, such as the American
Public Health Association-which has already developed a policy addressing
economic sanctions-and with the support of the American Medical
Association-which is the United States's voice in the World Medical
Association-the College hopes to be able to better protect the health of all

The College supports the following: 

1. Excluding from sanctions humanitarian goods, such as food- and
health-related materials or medical supplies, that are deemed likely to
reduce the morbidity or mortality of civilians. 

2. Empowering qualified and neutral agencies to publicly and expeditiously
address humanitarian appeals for exemptions, to conduct and disseminate
analyses of the health effects of economic sanctions, and to monitor and
report the effects of the sanctions on an ongoing basis. 

3. Providing medical and health-related supplies and services to offset any
increased morbidity caused by sanctions. 

4. Monitoring and reporting the effective delivery of medical and
health-related materials. 

*Members of the Ethics and Human Rights Committee were Risa Lavizzo-Mourey,
MD (chair); Joanne Lynn, MD; Richard J. Carroll, MD; David A. Fleming, MD;
Steven H. Miles, MD; Gail J. Povar, MD; Vincent Herrin, MD; James A. Tulsky,
MD; Alan L. Gordon, MD; Siang Y. Tan, MD; and Lee J. Dunn Jr., JD, LLM.
Approved by the Board of Regents on 7 February 1999. 

Requests for Reprints: Lois Snyder, JD, Center for Ethics and
Professionalism, American College of Physicians-American Society of Internal
Medicine, 190 North Independence Mall West, Philadelphia, PA 19106. For
reprint orders in quantities exceeding 10, please contact Barbara Hudson,
Reprints Coordinator; phone, 215-351-2657; e-mail, 

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Bulletin of the New York Academy of Medicine. 1995;72:454-69. 

2. Garfield R, Santana S. The impact of the economic crisis and the US
embargo on health in Cuba. Am J Public Health. 1997;87:15-20. 

3. Garfield R, Zaidi S, Lennock J. Medical care in Iraq following six years
of economic sanctions. BMJ. 1997;315:1474-5. 

4. Ascherio A, Chase R, Cote T, Dehaes G, Hoskins E, Laaouej J, et al.
Effects of the Gulf War on infant and child mortality in Iraq. N Engl J Med.

5. The effect of the Gulf crisis on the children of Iraq. The Harvard Study
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6. Zaidi S, Fawzi MC. Health of Baghdad's children [Letter]. Lancet.

7. Epidemic optic neuropathy in Cuba-clinical characterization and risk
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8. Cotton P. Cause of Cuban outbreak neuropathologic puzzle. JAMA.

9. Denial of Food and Medicine: The Impact of the US Embargo on Health and
Nutrition in Cuba. Washington, DC: American Association for World Health;

10. Eisenberg L. The sleep of reason produces monsters-human costs of
economic sanctions [Editorial]. N Engl J Med. 1997;336:1248-50. 

11. United Nations General Assembly. Universal Declaration of Human Rights.
General Assembly Resolution 217 A(III), 10 Dec 1948. 

12. United Nations General Assembly. International Covenant on Economic,
Social, and Cultural Rights. Resolution 2200A(XX), 16 Dec 1966. 

13. Doswald-Beck L, Vité S. International humanitarian law and human rights.
International Review of the Red Cross. 1993;293:94-119. 

14. Geneva Convention (IV). Relative to the protection of civilian persons
in time of war. 12 Aug 1949. 

15. Diplomatic Conference on the Reaffirmation and Development of
International Humanitarian Law Applicable in Armed Conflicts. Protocols
Additional to the Geneva Conventions of 12 August 1949, and Relating to the
Protection of Victims of Non-International Armed Conflicts (Protocol II). 8
Jun 1977. 

16. Kirkpatrick AF. The US attack on Cuba's health [Editorial]. CMAJ.

17. World Development Report 1993. Investing in Health. New York: Oxford
Univ Pr; 1993. 

18. Cassel EJ. The nature of suffering and the goals of medicine. N Engl J
Med. 1982;306:639-45. 

19. American College of Physicians. Ethics Manual. 4th ed. Ann Intern Med.

20. Grodin MA, Annas GJ. Legacies of Nuremberg. Medical ethics and human
rights [Editorial]. JAMA. 1976;276:1682-3. 

21. Pellegrino ED. The Nazi doctors and Nuremberg: some moral lessons
revisited [Editorial]. Ann Intern Med. 1997;127:307-8. 

22. Mann JM, Gostin L, Gruskin S, Brennan T, Lazzarini Z, Fineber HF. Health
and human rights. Health and Human Rights Journal. 1994;1:6-23. 

23. Leary VA. The right to health in international human rights law. Health
and Human Rights Journal. 1994;1:24-57. 

24. Ottawa Charter for Health Promotion. Presented at the First
International Conference on Health Promotion. Ottawa, Ontario, Canada, 21
Nov 1986. 

25. Hufbauer GC, Schott JJ, Elliott KA. Economic Sanctions Reconsidered:
History and Current Policy. 2d ed. Washington, DC: Institute for
International Economics; 1990. 

26. Boutros-Ghali B. Supplement to an agenda for peace: position paper of
the Secretary-General on the occasion of the fiftieth anniversary of the
United Nations. General Assembly, 50th session, document no. 60; 1995. 

27. Cassel C, Jameton A. Medical responsibility and thermonuclear war. Ann
Intern Med. 1982;97:426-32. 

28. Foege WH. Expanding the boundaries of medicine. Targeting a common enemy
[Editorial]. JAMA. 1991;266:702. 

29. Cole TB, Flanagin A. Violence-ubiquitous, threatening, and preventable
[Editorial]. JAMA. 1998;280:468. 

30. Lopez GA, Cortright D. Economic sanctions and human rights: part of the
problem or part of the solution? International Journal of Human Rights.
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