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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: http://www.acponline.org/shell-cgi/letter-article.pl Regards, Drew Hamre Golden Valley, MN USA --- http://www.acponline.org/journals/annals/18jan00/albright.htm Annals of Internal Medicine EDITORIAL Economic Sanctions and Public Health: A View from the Department of State Annals of Internal Medicine, 18 January 2000. 132:155-157. 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, email@example.com. 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. References 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. --- http://www.acponline.org/journals/annals/18jan00/morin.htm Annals of Internal Medicine POSITION PAPER The Health Effects of Economic Sanctions and Embargoes: The Role of Health Professionals Annals of Internal Medicine, 18 January 2000. 132:158-161. Karine Morin, LLM, and Steven H. Miles, MD, for the Ethics and Human Rights Committee* 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 (1). 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 recommendations. 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 populations. Recommendations 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, firstname.lastname@example.org. References 1. Garfield R, Devin J, Fausey J. The health impact of economic sanctions. 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. 1992;327:931-6. 5. The effect of the Gulf crisis on the children of Iraq. The Harvard Study Team. N Engl J Med. 1991;325:977-80. 6. Zaidi S, Fawzi MC. Health of Baghdad's children [Letter]. Lancet. 1995;346:1485. 7. Epidemic optic neuropathy in Cuba-clinical characterization and risk factors. The Cuba Neuropathy Field Investigation Team. N Engl J Med. 1995;333:1176-82. 8. Cotton P. Cause of Cuban outbreak neuropathologic puzzle. JAMA. 1993;270:421-3. 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; 1997. 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. 1997;157:281-4. 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. 1998;128:576-94. 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. 1997;1:1-25. -- ----------------------------------------------------------------------- This is a discussion list run by the Campaign Against Sanctions on Iraq For removal from list, email email@example.com Full archive and list instructions are available from the CASI website: http://welcome.to/casi